
By Charles Talamon, M, D 



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Nervous Exhaustion. 



HORSFORD'S ACID PHOSPHATE. 



Recommended as a restorative in all cases where the 
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It is readily assimilated and promotes digestion. 

Dr. Edwin F. Vose, Portland, Me., says: "I have pre- 
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Send for descriptive circular. Physicians who wish to test it will be 
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Prepared under the direction of Prof. E. N. Horsford, by the 

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Beware of Substitutes and Imitations. 



APPENDICITIS 

— AND — 

PERITYPHLITIS 

yC 

CHARLES TALAMON, M. D., 



Physician to Tenon Hospital, 
Paris, France. 



Translated by E. P. Hurd, M. D. 




1898. 
GEORGE S. DAVIS. 

DETROIT, MICH. 






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Copyrighted by 
GEORGE S. DAVIS. 



TABLE OF CONTENTS. 



I. 

Page 
Historical and Critical Resume 1-24 

1. The Typhlitis of Albers of Bonn 2 

2. Perityphlitis and Iliac Phlegmon 4 

3. The Stercoral Engorgement of the Caecum 8 

4. Ileo-caecal Perforations 11 

5. The Appendicitis of the American Authorities. ... 14 

6. Appendicular Colic 19 

7. The Part of the Caecum 22 

II. 

The Lesions 25-63 

8. The Vermiform Appendix 25 

9. Scybala 30 

10. The Microbes and their Role 37 

11. Lesions of the Walls of the Appendix 44 

12. Peri-appendicular Lesions 51 

13. The Perityphlitic Abscess 58 

III. 

The Causes 64-75 

14. Predisposing Causes 64 

15. Occasional Causes 73 

IV. 

The Symptoms 76-144 

16. Hyperacute Perforative Appendicitis 79 

17. Simple Parietal Appendicitis with Appendicular 

Colic 88 

18. Acute Appendicitis with Localized Peritonitis 98 

19. Subacute Appendicitis 112 

20. Chronic Relapsing Appendicitis 120 

21. Gravity of the Different Varieties of Appendicitis 137 



V. 

Page 
The Errors of Diagnosis 145-179 

22. The Pain 147 

23. Phenomena of Internal Strangulation 155 

24. The General Symptoms 158 

25. The Tumor 162 

26. Diagnosis of the Forms of Appendicitis 170 

VI. 

The Treatment 180-210 

27. The Medical Treatment 183 

28. The Surgical Treatment 189 

29. The Operation 200 

30. Treatment of Relapsing Appendicitis. 206 



TRANSLATOR'S PREFACE. 



Dr. Charles Talamon is one of the younger men in the 
medical profession in France who is fast earning a wide repu- 
tation as a writer. 

His first work, " Etudes Medicales," was published in 1881. 
It was written in conjunction with Prof. Lecorche, and has 
been a favorite with students of medicine, discussing in a 
masterly manner the deepest problems of medical science. 

In the volume of Prof. Germain See, published in 1885, and 
entitled "Diseases of the Lungs of a Specific, not Tuberculous 
Nature," the larger part, and particularly the long and strik- 
ingly original chapter on Pneumonia, is the work of Talamon, 
and in the book by See on "Simple Diseases of the Lungs," 
published the following year, a considerable portion was also 
written by him. 

Talamon, in conjunction with Prof. Lecorche, is also the 
author of a work on Bright's Disease, published in 1888, which 
is now a standard text-book on that subject. It is a very 
critical and exhaustive treatise, and merits a place in the 
library of all who are interested in renal diseases. In this 
work the unity of Bright's disease, in opposition to the 
dualism of Frerichs, Virchow and others, is ably defended. 

Talamon has done much good work in bacteriology, and 
made some valuable discoveries; his name will always be 
associated with the peculiar lanceolated coccus of acute pneu- 
monia, now known as the Talamon-Frankel microbe. 

The work here given to the American public is the first of a 
series 'originated by Charcot and Debove, and published by 
Rueff & Co. , of Paris. Although there has been much written 
on Appendicitis the past few years, it can hardly be said that 
any connected treatise on the subject had appeared till the 



VI 

publication of this work. The very name appendicitis was 
unknown ten years ago. 

In the light of recent pathology, typhlitis and perityphlitis 
independent of appendicitis must henceforth be relegated to 
the land of myths and fables. Stercoral typhlitis is destined 
to disappear from nosology, and idiopathic peritonitis is a 
bugaboo which no one ever saw or ever will see. When 
appendicitis and its coe sequences are once understood, many 
mysteries connected with peritoneal inflammations, deep 
abdominal abscesses, and other points of abdominal pathology, 
will have become clear. 

The present treatise is a good resume of what we have 
learned of appendicitis and perityphlitis since the disease was 
first defined and described by our own countryman, Dr. 
Reginald Fitz. No more practical and useful treatise could 
be offered the general practitioner, who is certain to see many 
cases of appendicitis every year, and who knows by sad experi- 
ence the fatality of this disease. 

E. P. HURD, M. D. 

Newburtport, Mass., Jan. 23, 1893. 



HISTORICAL AND CRITICAL RESUME. 

Physicians have long been agreed in admitting the 
clinical existence of an assemblage of morbid phe- 
nomena with the following characteristics: A fixed 
pain in the right iliac fossa, preceded or accompanied 
by abdominal colic, and followed by the formation of 
a painful tumor which ends more or less rapidly in 
resolution or in suppuration. But for the past sixty 
years, pathologists have disputed about the seat of 
the lesions — whether intra or extra caecal to which 
this syndrome belongs, nor has there been unanimity 
as to the name which should be applied to it. Some 
have called it a primary inflammation of the caecum, 
others, of the retro-peritoneal cellular tissue. Accord- 
ing to some, the caecal inflammation may propagate 
itself to the cellular tissue; according to others, it 
may determine by perforation of the intestinal 
walls, either a suppurative phlegmon or a peritoni- 
tis. The latter confound under the name of typh- 
litis all the inflammatory accidents of the region, 
whatever the seat; those who hold to the other view 
reserve this name for the inflammation when limited 
to the caecum. But Ziegler applies the name typh- 
litis to inflammation of the appendix, and peri- 
typhlitis to the inflammation of the adjacent parts. 
According to Burne, typhlo-enteritis is at the same 
1 



time inflammation and perforation of the caecum 
and appendix. Golbeck, who appears to have been 
the first to employ the word perityphlitis, reports 
under this name a case of peritonitis by perforation of 
the appendix. But Oppolzer would reserve this term 
for a limited inflammation of the peritoneal coat of the 
caacum and appendix, and proposes the name of 
paratyphlitis for the inflammation of the retro-caecal 
cellular tissue. 

The researches of the last ten years seem to have 
definitively established that the seat of the evil is not 
primarily in the caacurn or in the surrounding cellu- 
lar tissue, but in the appendix vermiformis. The 
word typhlitis, which means inflammation of the 
caecum, is then doomed to disappear and give place 
to the name appendicitis. 

1. The Typhlitis of Albers, of Bonn. 

Albers, of Bonn, is responsible for the description of typh- 
litis which has for nearly sixty years been curient in all our 
text books and treatises on pathology. He was the first to 
conceive, the notion of making of a limited inflammation of 
the caecum an affection distinct from the other varieties of 
entero-colitis and to ascribe to it the aggregate of painful and 
inflammatory phenomena already by other writers noticed in 
the region of the right iliac fossa; and he proposed for this 
affection the name of typhlitis. 

Albers recognizes four varieties of typhlitis: 

1. Stercoial typhlitis due to stagnation of faecal matters 
inthecseium, and to the irritation caused by these matters. 

2. Simple typhlitis, in relation with the divers agents of 
irritation which may provoke inflammation of the intestinal 
mucosa, the effects of this irritation localizing themselves in 
the mucous membrane of the caecum 



— 3 — 

3. Perityphlitis, caused by the propagation of the inflam- 
mation of the internal membrane to the external coat of the 
caecum and the surrounding' parts. 

4. Chronic typhlitis, whose accidents present themselves 
under the aspect of an affection with slow and prolonged 
course. ' 

Although this conception of Albers ultimately became cur- 
rent, and has continued to be so till the last few years, it met 
with determined opponents, one of whom was Grisolle. Even 
in the last edition of his treatise on Internal Pathology, this 
writer did not once use the name of typhlitis. Albers' disease 
was non-existent for him. He knew only the perforat ons of 
the ileo-caecal appendix and the phlegmons of the iliac fossa. 
He did not understand how simple inflammation of the mucous 
membrane of the caecum could have the grave consequences 
attributed to it, when ulcerous inflammation of the same 
mucosa, even when it causes deep and multiple losses of sub- 
stance as in typhoid fever or dysentery, shows no tendency 
to invade the surrounding cellular tissue. 

The stercoral typhlitis of Albers. none the less gradually 
won acceptance. It became the custom to refer inflammations 
of the iliac fossa to faecal engorgement of the caecum, and its 
consequences. All the treatises on the practice of medicine, 
one after another recognized under the name of typhlitis, an 
inflammation localized in the first part of the large intestine, 
which might terminate by resolution or by perforation, the 
perforation of the posterior part giving rise to a perityphlitis 
with abscess of the neighboring cellular tissue, perforation of 
the anterior part causing peritonitis. 

In point of fact, the notion of Albers is purely theoretical. 
It lacks the only serious and certain criterium which the path- 
ologist can demand, the proof furnished by pathological an- 
atomy. No one has ever seen on the cadaver either simple 
typhlitis or stercoral typhlitis. When, in cases where such a 
diagnosis has been made, the patients succumb, one invariably 
finds at the autopsy, either a perforation of the appendix, or 
a pericaecal abscess, or a peritonitis, but never a simple and 
isolated inflammation of the caecum. The writers who have 
defended this view have only succeeded in justifying it by 



1 Albers, Beobachtungen auf dem Gebiete der Path, und Path. Anat. 
Bonn 1838 and Journal 1' Experience 1839, p. 129. 



— 4 — 

systematically confounding the specific inflammations of the 
caecum, tuberculous, typhoid, and such like, the perforations 
of the appendix and their consequences. Even those who 
protest against this confusion and seek to maintain the 
specialization of the clinical type of typhlitis, when they 
come to the verification of this by the findings of the autopsy, 
report only observations of perforation of the appendix, or 
obscure and complex cases of which the interpretation may 
vary at the will of the critic. 

The first objection, then, which w r e wish to make to the 
typhlitis of Albers, is that it is without anatomo-pa hological 
proof. Let us now see into what elements this artificial con- 
ception may be decomposed. 

2. Perityphlitis and Iliac Phlegmon. 

The first and most important element is the puru- 
lent collection forming a tumor in the right iliac 
fossa. This tumor is the phenomenon which first 
attracted attention, as is proved by the title of the 
memoirs of Husson and Dance, 1 of Meniere and Gris- 
olle, " On phlegmonous tumors of the iliac fossa." Ac 
cording to Grisolle, the iliac abscess dominates the 
situation to this extent, that the gasto-intestinal 
symptoms are nothing but digestive disturbances 
such as may be observed in any febrile affection. 

But Dance and especially Meniere have looked at 
the question in the same way as Albers, and they 
may be regarded antecedent to him as the real inven- 
tors of typhlitis. Their observations, in fact, corre- 
spond exactly to the classic symptomatology and 
to the type which we shall describe further on under 
the name of sub-acute appendicitis; alternations of 
constipation, of diarrhoea, and colic continuing for 



Published in 1827. 



— 5 — 

weeks and months, fixed pain suddenly manifesting 
itself in the right iliac fossa, then the appearance of 
a painful tumor, which under the influence of leeches, 
of purgatives and lavements, progressively subsides 
at the end of a variable time. 

Meniere even reports' two cases in which he de- 
clares that the swelling could only have been pro- 
duced by the tumefaction of the walls of the caecum 
and colon; it was in fact the simple typhlitis of 
Albers. 1 

At the same time, he notes these observations without mak 
ing much ace >unt of them, and he speaks of the tumor in the 
right iliac fossa as always dependent on inflamma'ion of the 
pericecal cellular tissue. While recognizing etiolngically the 
determining part which the csecum takes in this cellular in- 
flammation, Meniere admits and describes only perityphlitis. 

For him, as for Dance, the iliac tumor is seated in the cel- 
lular tissue; it is a phlegmon which may terminate by resolu- 
tion—and he indicates the frequency of this mode of termina- 
tion,— or by suppuration, the abscess opening externally, or 
into the intestine or bladder. In certain cases, moreover, the 
inflammation may be propagated to the peritoneum, and the 
iliac phlegmon is complicated with peritonitis. 

Thi> view of Meniere, that the secondary inflammatory les- 
ions occupy the peri crecal cellular tissue, became and re- 
mained till the last few years, like the notion of Albers that 
the primary lesions are seated in the caecum, the expression of 
the truth for the greater number. 

At the same time, pathological anatomy does not enable us 
to verify either view. Of three things, one will take place: 
either the tumor will undergo resolution, or the abscess will 



1 Husson and Dance. Repertoire (Tanat. et de phys., 1827, t, iv. 
Meniere, Tumeurs phlegmoneuses occupant la fosse iliaque droit. 
Arch, de Med., 1828, t, xvii. Grisolle. Tumeurs phlegmoneuses dea 
fosses iliaques, Arch, de M6d, 1839. 



— 6 — 

burst or be opened by the bistoury, or the patient will suc- 
cumb. 

In the case of the tumor undergoing resolution, no con- 
clusion can be drawn respecting the precise seat of the lesions. 

In the second case, no certain data are afforded, whether 
the abscess open of itself or be opened. How are you going 
to tell whether the pus came from the sub-peritoneal cellular 
tissue, or from the peritoneum, after localization and encyst- 
ment of the inflammation? 

In the third case the subject succumbs; does the autopsy 
furnish a decisive answer? 

First, it tells only what is found in th ; s particular case, 
and logically, one is scarcely warranted in generalizing with- 
out the most thorough examination. Then such autopsies are 
very rare, which fact commands and justifies a prudent reserve 
in making deductions. Lastly, look over the published autop- 
sies, and see how difficult it is to understand the proper rela- 
tion of parts when the tissues of the region are disorganized 
by a long suppuration. Without doubt, in some cases the 
abscess seems to be extra-peritoneal; but generally one finds 
at t;ie same time united the inflammation of the cellular tissue 
and that of the peritoneum, and in the midst of muscles soft- 
ened, infiltrated, gangrenous, of pus-pockets, ot organized 
bands and intestinal adhesions, it is materially impossible to 
decide if the suppuration began inside or outside of the peri- 
toneum, if it was first an iliac phlegmon or a limited periton- 
itis. 

Like the affirmation of Albers, respecting the primary seat 
of the pretended typhlitis, the affirmation of Meniere respect- 
ing the cellular tissue localization of the pericecal lesions lacks 
anatomical basis, nor does normal anatomy give it any more 
support. 

It has lonor been taught that the caecum is incom- 
pletely covered by peritoneum, being only invested 
by that membrane on its anterior and lateral aspect, 
while behind, it is directly in contact with the cellu- 
lar tissue of the iliac fossa. Bardeleben, Henle, 
Luschka had, however, maintained the contrary. The 
researches of Treves have shown that the old opinion 



is false, that the peritoneum envelops the caecum 
completely, as well behind as in front, and that the 
first portion of the large intestine is free in the peri- 
toneal cavity as is the point of the heart in the peri- 
cardium.' Turner, in France, has confirmed this 
datum. In 120 cadavers, he found but nine excep- 
tions to the rule; in these cases, the peritoneum was 
wanting, but only over a part of the caecum, viz., the 
upper third of its posterior aspect. 2 And Maurin, on 
examining more than 100 subjects, has verified the 
constant exactitude of the anatomical description of 
Treves. 3 

It is then impossible to admit, as a general rule, 
the process indicated by Meniere. The iliac tumor 
is not due necessarily to an inflammation of the peri- 
cecal cellular tissue. This we shall make plainer 
farther on. 

As for the word perityphlitis, it may be retained, 
but we must enlarge the restricted signification which 
the standard treatises have given to it, i. e., of a 
phlegmon consecutive to perforation of the posterior 
aspect of the caecum. We must understand by typh- 
litis every inflammation, peritoneal or extra-periton- 
eal, exudative or suppurative, produced in the imme- 
diate vicinity of the caecum or its appendix, as a direct 
consequence of lesions of these organs. 



1 Treves, Hunterian lectures, Brit. Med, Jour., 1885. 

a Tuffier, Arch, gin de Med., 1887, t, xix. 

8 Maurin, Essai sur Vappendicite, (These de Paris, 1891.) 



— 8 — 

3. Stercoral Engorgement of the Caecum. 

The accumulation or stagnation of faecal matters in 
the caecum is one of the bases of the theory of typh- 
litis. We do not deny this stercoral engorgement. 
But the question is to ascertain: 

1. If this stagnation exists in conditions where so import- 
ant a pathogenic role can properly be ascribed to it? 

2. If the accumulation of fecal matters is capable of deter- 
mining an inflammation of the mucous membrane of the 
caecum? 

3. If this accumulation, even supposing that it provokes an 
irritation of the large intestine, gives rise to the classic symp- 
toms of typhlitis? 

The stagnation, the caecal constipation exists, that 
is not disputed. It may be observed, first, in the 
victims of incorrigible constipation, as a natural con- 
sequence of intestinal torpor. The faecal matters 
accumulate ordinarily in the sigmoid flexure, but if 
the evacuation becomes insufficient, the engorgement 
ascends, little by little, gains the entire colon, and the 
caecum in its turn becomes obstructed. 

It is next observed in the course or as a sequel of 
an attack of simple appendicitis, whether because the 
anti-peristaltic contractions of the large intestines, 
provoked by the irritation of the appendix, force 
back the faecal matters into the right cul-de-sac, or 
because the muscular coat of the caecum being para- 
lyzed by reason of a violent painful excitation, the 
faecal contents of that gut cannot pursue their normal 
course towards the rectum, and accumulate in the 
first part of the large intestine distended by atony. 



— 9 — 

But is this accumulation capable of provoking a 
true inflammation of the caecal mucosa? Munchmeyer 
and Behier say this is impossible. Munchmeyer, com- 
bating the doctrine of Albers, does not believe in 
stercoral typhilitis. He thinks that generally there 
is no inflammation of the caecum, even after a consid- 
erable and prolonged dilatation of the organ. He 
reports several cases where the caecum had attained 
enormous dimensions, those of the stomach in an old 
woman of sixty-two years, those of the gravid uterus 
at the seventh month; the symptoms were those of 
internal strangulation, but there were no inflamma- 
tory phenomena. 1 

Behier does not any more than Munchmeyer be- 
lieve in the irritant action of faecal matters on the 
mucosa. He thinks that the stercoral stagnation is 
insufficient to determine an inflammation. He ap- 
peals to the argument that we see every day individ- 
uals affected with obstinate constipation with con- 
siderable accumulation of faecal matters and who 
present no symptom of intestinal inflammation. 

It is nevertheless commonly held that the prolonged con- 
tact of indurated faecal matters determines a special irritation 
of the mucosa of the large intestine, a muco-membranous irri- 
tation which manifests itself by the signs of glairy or mem- 
branous entero-colitis, with expulsion of viscous mucosities 
resembling the white of egg, or pellicles more or less thick 
ooking like bits of tape-worm or filaments of macaroni. 
Although we may contest the explanation given, and main- 
tain that the formation of indurated scybala is itself but the 



Munchmeyer, Deutsch, Med. Klin., 1860. 



— 10 — 

consequence, and not the cause of the secretory and motor 
troubles of the intestine let us concede this pathogenetic role 
of the faecal matters. In every case, the irritation thus pro- 
voked is purely superficial, and never ends in limited ulceration 
or gangrene of the walls of the intestine. That this secretory 
irritation may exist in the caecum at the same time as in the 
rest of the colon is possible; but there is nothing here compar- 
able to an acute inflammation propagating itself to the divert 
coats of the caecal cul-de-sac and causing perforation. 

May this superficial irritation at least provoke the clinical 
phenomena which are said to characterize typhlitis? Mem- 
branous colitis determines dull colicky pains, meteorism, 
sometimes indeed pains in the abdomen of an intense charac- 
ter with elevation of temperature, or phenomena whi h simu- 
late internal strangulation, but nothing which resembles the 
local symptomatology of appendicitis, and it is for the physi- 
cian to know how to differentiate and diagnosticate the conse- 
quences of the two affections. 

The evils which result from prolonged faecal obstruction 
of the colon and caecum have been sometimes sufficiently 
grave to cause death. Do we observe in these cases the symp- 
toms of stercoral typhlitis? By no means. Do we find at the 
autopsy ulcerous lesions of the colon and appendix? Never. 
The following case by Harley in Vol XI. of the Reports of 
St. Thomas Hospital show well that this faecal engorgement 
of the caecum has nothing in common with the symptoms or 
lesions of appendicitis. 

"A young boy 17 years old was admitted moribund to the hospital 
in such a state of prostration that no information could be elicited from 
him, Body extremely emaciated; skin dry and cold; hands and feat vio- 
let color; eyes excavated; pulse filiform; tongue moist and heavily 
coated; bellv was not tympanitic or distended; doughy feel, without 
elasticity. No pain. Patient died next day. 

At the autopsy, the small intestine was found empty; the mucosa 
injected and covered with mucus of purulent aspect; all the large 
intestine from the orifice of the appendix to two inches from the anus 
was absolutely stuffed with faecal matters. The col <n was contracted 
on its contents so as to appear knotty or bead-like. The caecum was filled 
with a voluminous mass of faeces weighing over a pound. These mat- 
ters being: removed, the mucous membrane appeared to be covered 
with a thick yellowish mucus, and in divers poiuts, principally in the 
caecum, it presented the signs of a lively inflammation. The other 
viscera were healthy. " » 



1 J. Harley. Faecal retention especially as it affects the caecum. 
:Loc. cit., p. 128.) 



— 11 — 

This patient died, it would seem, of stercoraemia. but 
surely he presented no symptoms of typhlitis, and yet the 
mucosa of the caecum was inflamed where it was in contact 
with faecal matters. 

We may then admit that the stercoral engorgement of the 
caecum is capable of provoking a certain degree of mucous 
inflammation, although, for our part, we believe that it is 
oftener rather the effect than the cause of this inflammation, 
but we cannot agree that the faecal stagnation determines 
by itself the morbid syndrome described under the name of 
typhlitis. 

4. Ilio-C^ecal Perforations. 

The perforation of the appendix vermiform is, as a 
pathological fact, has been long known. About the 
middle of the last century, we find cases reported in 
the Journal General de Medecine et de Chirurgie. 
The first in date is that of Mestivier published in 
1759. Mestivier gives the history of a man aged 45 
years, who entered the Hospital St. Andre de Bor- 
deaux to be treated for a tumor situated near the 
umbilical region on the right side. The tumor was 
fluctuating, was opened, and a pint of pus was dis- 
charged. The patient died. At the autopsy there 
was found as the starting point of the abscess a pin 
encrusted with earthy matter which had perforated 
the appendix. 

This was only a case of traumatic appendicitis; 
That of Wegeler published in 1813 is a clear example 
of stercoral appendicitis: 

A young man aged 18 years is attacked with slight colicky 
pains which continue for three days, then there supervenes an 
intense, continuous, circumscribed pain in the right iliac fossa, 



— 12 — 

increased by pressure; the belly is tense, there is constipation 
preceded by slight diarrhoea. Hiccough, retching and vomit- 
ing, first porraceous, then faecaloid. The next day, pinched 
features, cold extremities, and death during the night. 

iSectio Cadamris. — General peritonitis, caecum gangrenous. 
This morbid change, said the writer, seemed to have com- 
menced in the appendix, which was red, voluminous and con- 
tained several calculi of which the largest weighed about a 
gramme. ' 

The two observations of Louyer-Villermay 2 are similar. 

But the memoir of Melier, which appeared in 1827 
in the Journal general de medecine is one of the most 
remarkable and merits a detailed analysis. After 
having cited the two observations of Louyer-Viller- 
may, Melier reports four cases of which he had per- 
sonal knowledge. The three first are cases of perfor- 
ative appendicitis with fulminant peritonitis; the 
fourth a case of relapsing appendicitis. One of the 
cases was first thought to be only simple indigestion; 
another to be probably internal strangulation. It will 
be seen that these are, in fact, two of the aspects 
under which appendicitis often presents itself. 

Mel ier insists upon the existence in the three first cases of two 
•distinct phases, the one of abdominal colics more or less severe, 
the other of fixed pain localized in the right iliac fossa, followed 
by all the signs of acute peritonitis. " The patient," he says in 
commenting on his first case, "was subject to attacks of colic; 
he had had an attack of this kind for several days; he had partly 
recovered from these pains, when all at once in the midst of 
the lull, an intense pain came on in the lower part of the belly, 
followed by symptoms of spreading peritonitis and death in 
18 hours." 



1 Wegeler, Jour, de Med. et de Chir. de Corvisart, 1813. 

2 Louyer-Villermay, Arch. gen. de Med., 1824. 



— 13 — 

The two phases of the affection, appendicular phase and 
peritoneal phase, are here clearly indicated. Melier, more- 
over, has a clear notion as to the interpretation of the accidents. 
"I explain in this way the divers accidents and their suc- 
cession Faecal matters had accumulated in the appendix, 
which became dilated, then obstructed, by degrees inflamed, 
then gangrenous, lastly perforation occurred. The first acci- 
dents^', e. the colicky pains, were probably due to the distention 
and inflammation of the appendix. Its rupture gave rise to 
the effusion which itself seems to have been the cause of the 
peritonitis. " 

While mentioning the apparent rarity of these affections of 
the appendix, he adds: "Remark, nevertheless, that the four 
cases which are the subject of this memoir have been collected 
in a rather short interval of time, and two of them occurred in 
the practice of the same physician; which leads me to believe 
that if these affections have not been oftener observed, it is 
because sufficient attention has not been iiiven to the appen- 
dix, an organ regarded as of little importance, and of which 
the lesions are unnoticed at the autopsy because physicians 
neglect to look for them." 

He takes care, moreover, to state that these inflammations of 
the appendix should be distinguished from faecal accumulations 
in the caecum and colon, a very common affection, in his esti- 
mation, especially in women. This stercoral accumulation 
gives rise to symptoms qu te different from the lesions of ap- 
pendicitis, symptoms which, from their similarity to what 
takes place where there is retention of urine, he proposes to 
describe under the name of stercoral fever. 

Lastly, not only did Melier exactly see and explain the causes, 
the character and consequences of appendicitis, but he had an 
inkling of, and indicated the possibility of the surgical treat- 
ment. 

" If it were possible." says he, " to establish with certainty 
the diagnosis of these affections, we can see the possibility of 
curing the patient by an operation. We shall perhaps some 
day arrive at this result." ' 

Thus Melier had seen and understood the preponderant 
role of appendicular lesions in inflammations of the right iliac 



1 Melier. Memoir and observations on certain diseases of the ap- 
pendix vermiformis. Jour, de Med. de Chir. et de pharm. 1827 p. 317. 



— 14 — 

fossa, and this to the exclusion of the pretended faecal engorge- 
ment of the caecum. It onty remained to follow out the path 
so well indicated and traced by him in order to rapidly arrive 
at the point to which the question has been brought to day, 
but only after having for sixty years deviated from its point 
of departure. 

The memoir of Meniere which appeared the following year, 
the notion that the lesions occupy the cellular tissue of the 
right iliac fossa, later on, the memoir of Albers, caused the 
work of Melier to be completely lost sight of. Pathologists 
henceforth saw and wished to see only the caecum; they in- 
vented for the caecum a special pathology and even physiol- 
ogy; and the appendix continued to be regarded as "an organ 
of little importance, and of which at the autopsy all alike 
neglect to note the lesions." 

From time to time, however, appeared memoirs such as 
those of Boclart, of Favre, of Forget, of Leudet, adding new 
facts to the observations of LouyerVillermay and of Melier. 1 
But all these writers tend to separate the consequences or 
these perforations from the lesions and symptoms attributed 
to typhlitis. They saw in the perforation only an accident 
always fatal, and the cause of the general peritonitis. 

Thus, little by little the view became prevalent which still 
counts a few advocates, but which will henceforth count 
fewer and fewer, that the grave and fatal forms of typhlitis 
are due to perforation of the appendix, the benign and cur- 
able forms to an inflammation of the caecum and cellular tissue 
which surrounds it. 



5. The Appendicitis op Americans. 

The surgeons and physicians of the United States 
have restored the question to the status to which 
Melier had advanced it, and by their early operations 
have demonstrated that in every case, grave or 



1 Bodart, Th. Paris 1844. Favre. Th. Paris 1851. Forget. On peri- 
tonitis by perforation of the appendix vermiformis. (Gaz. Med. de 
Strasbourg, 1855.) Leudet. Arch. gen. de Med., 1859. 



— 15 — 

benign, the appendix is always the primary seat of 
the lesions. 

The epoch-making memoir on this subject is the 
paper of Reginald Fitz, of Boston, published in the 
American Journal of Medical Sciences for October, 
1886, "On Perforative Inflammation of the Vermi- 
form Appendix." In this work Fitz collected 209 
cases of typhlitis and perityphlitis, and 257 cases of 
perforative appendicitis. He showed that the symp- 
toms are the same in the latter as in the former class 
of cases. He studied with care the consequences of 
perforation. He established the fact that the peri- 
tonitis is not always generalized, that it may be cir- 
cumscribed under the form of an encysted purulent 
collection. He gave the characters of the tumor 
formed by this localized peritonitis, the different 
modes of the evacuation of the pus, the complications 
that may supervene if the disease is left to itself. 
He insisted on the frequency of faecal concretions as 
a cause of the perforation of the appendix. He con- 
cludes in favor of early surgical interference. 

It is only just to say that most of these facts had been 
pointed out before in Europe. In 1879 Biernier said that per- 
ityphlitis is always the consequence of a perf oral ion of the 
appendix caused by a stercoral concretion. Matterstock, in 
1880, called attention to the frequency of concretions in the 
etiology of these perforations. With, at the Congress of Copen- 
hagen, declared that the lesions of appendicitis may occasion 
three kinds of peritonitis; a generalized peritonitis, a circum- 
scribed peritonitis, and an adhesive peritonitis. He even 
affirmed that the typhilites which terminate by resolution are 
nothing but adhesive appendicular peritonites. I myself, in 



— 16 — 

1882, in calling attention to the pathogenic role of scybala, 
showed that the foreign body does not perforate the appendix 
after the manner of a traumatic agent, but in strangulating or 
obstructing the circulation of the walls of the canal, it favors 
the microbic inflammation of these walls and consequently 
their gangrene and ulceration. 

Pathologists could now no longer overlook the im- 
portance of the role of the appendix, yet they none 
the less continued to admit along with perforative 
inflammations of this organ, csecal and pericecal in- 
flammations having their origin in the caecum. 

In a second paper, the complement of the first, Fitz 
in 1 888 took the radical but scientific position that the 
states described under the names of typhlitis, of peri 
or para-typhlitis, of appendicular peritonitis, or peri- 
typhlic abscess, were all nothing but phases or vari- 
ieties of one and the same affection, inflammation of 
the appendix veriformis, or appendicitis. 1 

We have here the gist of all the discussions and 
memoirs pertaining to typhlitic affections which have 
appeared in the United States during the past six 
years. 

Although no didactic description has been given 
of appendicitis, and all the writings which per- 
tain to the subject are found scattered in the journals 
and reports of the medical societies of Boston, New 
York and Philadelphia, it is easy to see that there is 
unanimity among American authorities, 2 on this point 

i Reginald Fitz, New York MedicalJournal, May 12, 1888. 

2 MacBurney, Bull, J. Lewis Smith, Sands. Weir of New York, Porter, 
Elliot, Warren, Monks, Worcester, and Richardson, of Massachusetts, 
MacMurtry of St. Louis, Keen, Morton, Price of Philadelphia , Senn of 
Chicago, etc., etc. 



— 17 — 

that whenever the surgeon operates for relief of 
symptoms attributed to typhlitis or perityphlitis, it 
is always the appendix which he finds primarily 
affected. 

This same notion I have myself defended from a 
medical and pathogenic point of view in a series of 
articles published last year in La Medecine Modeme; 
and I have shown how perfectly all the symptoms of 
typhlitis are explained if we locate in the appendix 
the first cause of the irritation. The present work is 
but the development of this pathogenetic theory 
applied to the clinical evolution of the divers forms 
of appendicitis; and as for the description of these 
forms, we may say that it is based entirely on the 
result of the American operations. 

These operations, made very early, from the second 
or third day of the disease, and often for cases which 
would have got well by medical treatment, have 
enabled us to study devisu all the varieties of appen- 
dicitis, from those slight forms where hardly any 
lesions exist, to the most grave forms with localized or 
diffuse peritonitis. 

They also show that there never or almost never 
exists inflammation or perforation of the caecum; 
not once in 200 cases according to MacMurtry. 1 
If Ave refer to the statistics of writers who still 
admit the existence of a typhlitis distinct from 



MacMurtry, Med. News, Jan. 10, 
2 



appendicitis, those of Maurin, for instance, who has 
collected 136 cases occurring in France, we shall find 
that the appendix alone was the seat of lesion in 
94 cases, the caecum alone in 36, the appendix and 
the caecum in six. But if we analyze these 36 
cases where the caecum is considered as alone the 
seat of lesion, in 20 the disease terminated in re- 
covery, i. e., there was no means of determining the 
Teal seat of the lesions, and it was solely by tradi- 
tional conviction that these cases were attributed to 
an alteration of the caecum rather than to a lesion of 
the appendix; in two the caecum was perforated by a 
foreign body, a pin or a fish bone; in two, it is indeed 
said that the caecum presented some redness and in- 
jection of the mucosa, but no mention is made of the 
appendix; in 12 only it is distinctly noticed that the 
caecum was the seat of a perforation. We still wish 
to know if in these twelve cases the perforation was 
really the result of simple inflammation, if it was not 
due to a tuberculous ulceration, if sometimes it was 
not secondary to the bursting inward of a peri-caecal 
abscess; conditions, all of them, concerning which the 
statistics are silent. 

We are, in fact, warranted in distrusting these old 
observations, taken at a time when the true role of 
the appendix was not suspected, and we only regard 
as trustworthy, facts collected with full knowledge 
of causation. If you read the two memoirs of Roux, 
of Lausanne, which assigns the origin of the malady 



— \\) — 

sometimes to the caecum, sometimes to the appendix!, 
you will see how little remains of the typhlitis of 
Albers. But of 17 cases where Roux, on opening the 
abdomen was able to verify the seat of the primary les- 
ions, in 46 he found the appendix inflamed or per- 
forated; and in one only the appendix was sound and 
the symptoms were due to a perforation of the caa- 
cum. 

We shall presently consider the part which belongs 
to the caecum in certain periods of the disease, but 
it is very evident that the part which it plays in the 
pathogeny of the accidents must be ascribed wholly 
to the appendix vermiformis. 

6. Appendicular Colic. 

The American writers have had chiefly in view 
the practical and surgical side of the question, and 
have scarcely touched upon the pathogenic side. 
While setting forth and illustrating the frequency of 
foreign bodies and especially of scybala as cause of 
perforative appendicitis, they have limited them- 
selves to noting the fact without seeking to pene. 
trate the mechanism of the perforation. 

Moreover no one has yet explained the sudden 
mode of onset of the symptoms, the attack of colic 
which precedes the perforation, and which in some 
cases almost constitutes the disease in its entirety. 

The suddenness of the onset is nevertheless quite 
peculiar and characteristic. This fact taken into con- 



— 20 — 

sideration along with the frequency of stercoral cal- 
culi in the cavity of the appendix, inspired me with 
the idea of the pathogenic theory indicated in a 
number of my journal for 1890, and which seems 
sufficient to explain the different varieties of appen- 
dicitis. 1 

We compare the diverticulum of the appendix to 
a musculo-membranous tube like the choledochus or 
ureter for instance. A gall-stone in becoming en- 
gaged in the choledochus, determines an attack of 
hepatic colic, with its characteristic symptoms: sud- 
den onset, local pains, radiating and paroxysmal 
pains, vomiting. The same effects result from the 
engagement of a uric acid-calculus in the ureter. 

So also an intestinal concretion, on suddenly, pene- 
trating the appendicular canal, provokes a sudden 
pain localized in the right iliac fossa, pains radiating 
and paroxysmal under the form of intestinal colic, pre- 
dominating especially in the right side of the abdomen, 
vomiting, and constipation by reason of paresis of the 
large intestine. Are not these symptoms exactly those 
of the affection called typhlitis simple or stercoral? 
According to the old view, they are due to intestinal 
obstruction, but the arrest of faecal matters is posterior 
and not anterior to the attack of pain. The constipa- 
tion, like other symptoms, is due not to an obstruc- 
tion, which does not exist, but to the reflex irritation 



1 Charles Talamon, Appendicitis and Typhlitis. Medecine Moderne. 
Jan. 19, 1890. 



— 21 — 

of the mucous membrane of the appendix, just as 
the pain, the vomiting, and constipation of hepatic 
colic are provoked by a reflex irritation starting from 
the mucous membrane of the choledochus. 

Even the fa>caloid vomiting which may supervene 
in appendicitis, in no sense implies an obstruction of 
the intestine. We know that this kind of vomiting 
is observed in cases of intestinal paresis without any 
mechanical obstacle to the passage of freces. 

The painful crisis of appendicitis with sudden on- 
set is due, in my judgment, to the same cause, pene- 
tration of a hard body in a narrow and sensitive duct; 
and the same mechanism, a painful irritation reflected 
upon the innervation of the neighboring organs, as 
is the case with hepatic and nephritic colic. We call 
it consequently appendicular colic, and believe that 
this appendicular colic may sometimes exist by itself, 
sometimes represent the first phase of morbid acci- 
dents which end in perforation of the appendix and 
in general or local peritonitis, the consequence of this 
perforation. 

If the first effects of the engagement of the calcu- 
lus are the same in the appendix and in the choledo- 
chus, the secondary effects of the obstruction differ 
in the two cases. In hepatic colic, the morbid acci- 
dents may cease in two ways; either the calculus falls 
back into the gall-bladder or it gradually passes down 
into the intestine. In appendicular colic, the pain 
will cease by only one mechanism, the expulsion of 



— 22 — 

the coprolith into the caecum; the disease then goes 
no farther than an attack of colic and a certain de- 
gree of appendicitis. 

As in hepatic colic, moreover, a first attack favors 
the production of new attacks, by leaving the orifice 
of the canal dilated and more ready for the engage 
ment of new concretions; in other words, the patient 
is subject to recurrent or relapsing appendicitis. 

In hepatic colic, if the calculus remains engaged in 
the choledochus the sole consequence is chronic 
icterus. This enclavement may persist for weeks and 
months without any other consequence. The perfor- 
ation of the canal at the level of or behind the ob- 
stacle is a rarity, despite the pressure exercised by 
the bile which continues to be secreted, because the 
bile is an aseptic liquid and there exist no microbes 
in the normal state on the surface, of the biliary 
mucosa. In appendicitis, on the contrary, perforation 
is the rule, because the parietes, deprived of their 
vitality by compression of the vessels, no longer offer 
any resistance to the penetration of the bacteria 
which multiply and thrive in the dilated cavity. 

7. The Part of the Caecum. 

It will be seen that we completely dispossess the caecum of 
the role which tradition has assigned to it in the production 
of the morbid accidents described under the name of typhlitis. 
Neither the tumor, nor the pain, nor the inflammatory pheno- 
mena are due to any lesion of the walls of the caecum proper. 

But do we mean by this that this part of the large intestine 
may not be the seat of morbid alterations whose predominence 



at this level determines sometimes symptoms more or less 
similar to those of appendicitis or to those of appendicular 
peritonitis? Certainly not. We do not dispute the existence 
of ulcerations of the caecal mucosa in the course of dysentery, 
typhoid fever, of tuberculoses, of syphilis, even. Intestinal 
tuberculoses may even begin by the caecum. On the other 
hand. Bauhin's valve (ileo-caecal valve) is one of the seats of 
predilection of cancer of the intestine 

All these lesions may give rise to signs of pain and of 
swelling localized in the right iliac fossa which are liable to 
be confounded with the symptoms of subacute appendicitis 
with insidious march. I shall return to this subject when I 
come to diagnosis. 

We may, if we wish, give to these lesions the names of 
typhlitis-dysenteric, typhoid, tuberculous, cancerous, — but in 
my judgment this would be. wrong; first, because in accord- 
ance with the classic conception of typhlitis, these specific 
alterations of the caecum have generally been classified apart 
and distinguished from inflammatory typhlitis properly so 
called. In the second place, these lesions — with the exception 
of cancer — are very r rely exactly limited to the caecum, and 
ordinarilv extend to other parts of the large intestine. Lastly, 
it is very exceptional that ulcerations of this kind give rise to 
symptoms which one feels inclined to specialize and to localize 
in the caecum. And here is just one of the most striking argu- 
ments against the existence of this pretended stercoral typh- 
litis. When caecal lesions exist, tangible and indisputable, 
the symptoms and signs of typhlitis are lacking. What right 
have we when these siuns and symptoms are present, to refer 
them to an inflammation of the caecum, when no one has ever 
seen any such inflammation attended with such symptoms? 

It may be asked whether in the course of appendicitis with 
or without perforation, the caecum may take part in the mor- 
bid process? Without doubt the caecum may be interested, 
but always in an accessory and secondary manner. 

1. By the very reason of its propinquity to the perforated 
appendix, the peritoneum which envelops the caecum is 
always the most rapidly and the most profoundly affected; it 
is here that the false, fibrinous membranes are the thickest 
and most abundant. 

2. The appendix being very often applied against one of 
the sides of the caecum, the purulent collection, consequence 
of the appendicular perforation, often points behind or on one 



— 24 — 

of the lateral aspects of this part of the colon. If the abscess is 
left to itself, it frequently bursts into the caecum, perforating 
its coats from without inwardly; this is one of the modes in 
which pus is evacuated, and one of the ways of recovery in 
perityphlitis. 

3 Daring a crisis of appendicitis one will sometimes (though 
rarely) feel in the right iliac fossa an elongated tumor, more 
or less cylindrical, of pasty or hard consistency, formed by 
faecal matters accumulated in the caecum. This tumor which, 
to the advocates of stercoral typhlitis is the very cause of the 
morbid accidents, is really only the consequence. It is never 
felt in the onset of the disease, but only after several days 
when the pain is assuaged and the contractions of the abdomi- 
nal muscular plane are in the process of giving way; and it 
is scarcely ever noticed except in recurrent appendicitis after 
one or more crises of appendicular colic. The accumulation 
of faeces is brought about, both by reason of the anti- 
peristaltic contractions of the large intestine, consecutive to 
the painful excitation of the muscular coat, faecal matters 
which normally belong to the second half of the colon being 
forced back into the caecum; and by reason of paralytic 
atony of this same muscular coat, which, being violently 
excited during the painful crisis, becomes then powerless to 
propel the faecal masses in their ordinary direction. 

4. This paralytic atony with faecal stagnation may be re- 
placed in other cases by an atony with gaseous dilatation. 
You will perceive then in the caecal region an exaggerated 
tympanitic sonorousness, accompanied by localized borbo- 
rygmi. The motor paresis which is predominant in the 
caecum, exists moreover in the whole of the large intestine, 
and this explains the obstinate constipation from which per- 
sons affected with relapsing appendicitis suffer. 

On the whole, the signs furnished by the examination of 
the caecum are those of simple paretic distention and not of 
inflammation. These signs are always secondary, and consec- 
utive to the appearance of the symptoms due to appendicitis. 

Ulcerous inflammation of the caecum, however, exists in 
divers specific diseases; but this inflammation rarely, if ever, 
gives rise to a symptomatology offering any similarity to that 
of classic typhlitis. 

In order that the symptoms described under the name of 
typhlitis may be produced, it is necessary that the appendix 
shall be primarily affected. 



II. 

THE LESIONS. 

8. The Appendix Vermiformis. 

The appendix vermiformis is a diverticulum of the 
large intestine attached to the postero-internal part 
of the caecal cul-de-sac, or caput coli. It is an 
atrophied organ, a rudimentary vestige representing 
in man the developed caecum of Herbivora and Rod- 
ents. Confounded during embryonic life with the 
large intestine, it contracts little by little and be- 
comes reduced at the moment of birth to the size of 
a goose-quill, while preserving a variable length. It 
would be useless to discuss the functions and physio- 
logical role of the appendix; it has none, and the 
dangers to which it exposes man are alone potent and 
incontestible. If the physiologist has little inter- 
est in the study of this organ, it is not so with the 
physician who has long had the misfortune to devote 
to it but slight attention, and to see in its perfora- 
tions only an accidental traumatism. The appendix 
is a useless organ, but at the same time an organ 
essentially injurious. 

Its structure does not differ from that of the intes- 
tine; the walls are composed of four coats which, 
from within outward are: the mucosa, containing 
tubular glands and perhaps closed follicles; a connec- 
tive tissue stratum separating the mucosa from the 



— 26 — 

muscular coat which is formed of longitudinal and 
circular fibres; lastly, the serous coat represented 
by the peritoneum. 

The points which interest us in the anatomy of the 
appendix are its dimensions, situations and exact re- 
lations with the peritoneum. 

1. Dimensions. — Its dimemsions are extremely variable. 
Sappey ascribes to it the average size of a goose-quill, and a 
length of 6 to 12 centimetres. But cases are cited where the 
appendix was found no larger than a little tubercle (Merling), 
or where it was absolutely wanting (Ferguson), and others 
where it had attained the length of 25 to 50 centimetres, with 
a size equal to that of the finger. 

Ferguson, who has examined with care and measured 200 
appendices, gives as the average length 4£ inches, and for 
diameter that of a No. 9 English sound. In three cases the 
appendix was only a half-inch long, and in one there was no- 
trace of this organ to be found. 1 

Normally, the internal canal is very narrow as compared 
with the thickness of the walls. Besides the orifice of com- 
munication with the caecum is ordinarily half-closed by a 
semi-lunar fold of mucous membrane called the valoe of 
Oerlach. In normal conditions, then, it is not easy for a 
foreign body to penetrate the appendicular canal; it can enter 
only by effraction (so to speak), by forcing the orifice and 
dilating the caliber of the duct. 

2. Sitaatioji. — The situation of the appendix in the 
abdomen is important to know, now that the excision of this 
organ has become an operation of such frequent occurrence. 
There are two points to determine : its insertion in the caecum 
and its general position in relation to the intestine. The 
insertion takes place at the posterior and internal part of the 
head of the olon. This point corresponds to the middle of a 
line drawn from the anterior superior spine of the ilium to the 
umbilicus. 2 This is the point of maximum intensity of the 



1 Ferguson. Some points regarding the Appendix Vermil'orinis- 
(Am. Jour. Med. Sc, January, 1891.) 

2 MacBurney's point. 



fixed pain which indicates inflammation of the appendix, and 
it is there that you are to seek for the organ when you wish 
to tie it and resect it. 

As for the position of the free part and its relations with 
the neighboring organs, they are far from being always the 
same. In the 200 cases studied by Ferguson, the direction 
and the situation of the appendix were the following: 

In 19 cases the appendix was placed on the external 
aspect, on the right side of the caecum ; in 11 its direction was 
downwards ; in 18 its direction was inwards ; in 75 it was in 
relation with the posterior part of the caecum. Lastly, in 77, 
it was so placed in the iliac fossa that its perforation would 
necessarily take place into the retro peritoneal cellular tissue, 
and would thus cause an abscess in the iliac region. 

Remark the frequency of its relation with the posterior 
face of the caecum. In this position Sappey says that he has 
seen the appendix ascend as high as the lower border of the 
liver, and enter into contact by its extremity with the gall 
bladder. Hartley in 15 cases found the appendix behind the 
head of the colon in eight ; behind and a little inward, once ; 
below and in part behind, once , below and in relation with 
the anterior abdominal wall, once ; below and in part on the 
anterior aspect of the caecum, once : on the brim of the 
pelvis inside the caecum, once ; on the internal aspect of the 
caecum, once ; on its anterior aspect, once. l 

According to Briggs (Post Graduate, New York, Novem- 
ber, 1889). in almost three-quarters of the cases the appendix 
is directed below and inwards ; in a little more than one-fourth 
of the cases it is situated behind the caecum and ascending 
colon. 

These variations of relation and direction of the appendix 
explain several things : 1. How palpation, in endeavoring to 
localize the pain and tumefaction, may lead to the belief in 
an inflammation of the caecum when there is only a lesion of 
the appendix attached to the caecum ; 2. How purulent 
collections of appendicular origin do not always occupy the 
same seat, since the perforation of the appendix may take 
place sometimes inwardly, sometimes outwardly, sometimes 
behind the caecum ; 3. They show lastly, how the surgeons 
who even to-day rely on the seat of the purulent collection in 
establishing a distinction between appendicitis and perity- 



N. Y. Med. Rec, August 16th, 



— 28 — 

•phlitis, and in maintaining that not every perityphlitis is in 
relation with a lesion of the appendix, only display by such 
reasoning their ignorance of the variable anatomical rela- 
tions which the diverticulum may present. 

8. Relations with the peritoneum. — A. last detail, of no less 
interest to determine, is the relation of the p ritoneum to the 
appendix. Most anatomists have claimed that the appendix 
as well as the caecum is incompletely covered by the serosa, 
and that, as a general rule, a part of its circumference, the 
posterior and superior portion, is in direct contact with the 
subperitoneal cellular tissue. 

The attentive study of the region proves the contrary. 
Maurin says that out of 112 subjects of all ages, he has in all 
of them seen the appendix completely surrounded by the 
serosa, and quite free in its cavity. 1 One may well, think 
that Maurin fell upon a special series of subjects, for it cannot 
be denied that in a certain number of cases the appendix is 
in direct relation with the retro-csecal cellular tissue. Fergu- 
son's statistics seem to me more conformable to the reality. 

In 200 cases, Ferguson found the appendix in 128 invested 
with its proper mesentery and free in the peritoneal cavity. 
But in 77 of these cases the appendix was covered by 
peritoneum "in such a way that perforation could only take 
place into the sub-peritoneal cellular tissue, thus producing a 
diffuse form of cellulitis." 

As a general rule, the appendix then, floats freely in the 
abdominal cavity, but in a third, at least, of the cases it is in 
contact, in a part of its length, and sometimes in its whole 
length, with the sub-peritoneal connective tissue. 

4. Frequency of appendicular lesions. — The researches of 
the past few years have established the frequency of lesions, 
which take place, in a more or less latent manner, in the 
interior or on the exterior of the appendix. 

Hekto8n, of Chicago, and Maurin have noted the exterior 
alterations. The first, in 280 autopsies found adhesions in 42, 
the vestiges of a former peri-appendicitis (15 per cent.). 
Maurin, in 113 autopsies, found in 16 periappendicular 
adhesions, the relics of localized peritonites, "while nothing 
in the antecedents of the subjects had ever called attention in 
that direction " 

The examinations of Toft pertained both to the external 



1 Maurin. Loc cit. p. 



aspect and the internal cavity of the organ. In a total of COO 

autopsies Toft noted evident signs of appendicular lesions in 
the proportion of 36 per cent. 

The proportion indicated by Ferguson is considerably less. 
Out of 200 post-mortem examinations lie found only seven 
cases where there was evidence of old lesions or of perfora- 
tion. In three of these cases it was in fact proved that there 
had been perforation in a past time In 15 cases there were 
found foreign bodies in the canal of the appendix, fruit seeds, 
scvbaJa, etc. 

In summing up these different statistics we may then 
conclude that in 2i) per cent, of cases we meet with appendic- 
ular lesions, internal or external, at the autopsy of subjects 
who have succumbed to divers affections. 

Are we to infer that these old lesions, intra or extra 
appendicular, remained absolute^ latent during life ? Ord d 
they manifest themselves at a given moment by symptoms, 
more or less plain, of an abdominal affection ? It is 
impossible to say, as the statistics do not give us any clinical 
information. It nevertheless seems difficult to admit, 
considering the susceptibility of the peritoneal serosa, that 
these lesions could have remained completely silent or latent. 
On the other hand, Maurin took care to note that nothing in 
the antecedents of his 16 patients gave any hint as to the lesions 
which were found at the autopsj^. If, then, these patients 
had at any time any abdominal symptoms, these were of too 
little gravity to leave behii d anything but a vague remem- 
brance of a disorder for which they did not deem it necessary 
to call a physician. 

We are ihen justified in thinking that appendicitis is not 
necessarily attended with violent symptoms, and that slight 
and transitory forms occur, whose signs are but little marked, 
and generalhy, doubtless, misunderstood, being interpreted as 
intestinal colic, abdominal neuralgia, etc. 

But this frequency of appendicular lesions leads yet to 
another conclusion of some practical importance. It is not 
proved that these lesions are always only in relation with 
light attacks ; there are cases where, as in the three patients 
of Ferguson where the clinical existence of appendicitis with 
perforation had been noted in the antecedents of the subjects, 
serious symptoms had been observed during life. We thus 
have the anatomical proof that grave forms of appendicitis may 
get well spontaneously, a fact which clinical observation has 



— 30 — 

no less formally demonstrated, and consequently we find a 
new justification for the reserve which many manifest in 
regard to surgical intervention. 



9. SCYBALA. 

In the anatomo-pathological study of appendicitis 
one fact ought to be at once made emphatic, namely 
the frequent, not to say constant, detection of hard 
concretions or of foreign bodies in the cavity of the 
inflamed appendix. Out of a total of 760 cases of 
appendicitis obtained by collecting the statistics and 
observations of divers authorities, Fitz, Matterstock, 
Krafft, Fenwick, Maurin, Roux, etc., in 450 the pres- 
ence of such foreign bodies was noted in the appen- 
dix itself, sometimes in the pus of the peri-appendic- 
ular abscess (60 per cent). We shall presently see 
how the absence of concretions or of foreign bodies 
in observations where the writers make no mention 
of this important detail is to be explained. 

These foreign bodies are of various kinds: some- 
times pointed bodies, like pins or fish bones, capable 
themselves of perforating the intestinal walls; some- 
times round, like seeds, pepins, fruit stones, beans, 
gall stones, or intestinal calculi; lastly, hard faecal 
balls, or scybala. 

The comparative frequency of these different varie- 
ties of foreign bodies deserves a moment's attention. 
Scybala are by far the most frequent of all. Thus 
Reginald Fitz in 132 cases found scybala in 47 per 



— 3 J — 

cent; Matterstock in 57 out of 69 cases; Kraft in 36 out 
of 40 cases; Maurin in 34 out of 60 cases. Fen wick's 
figures alone differ in the result: foreign bodies in 55, 
and faecal balls in 14 cases. 

We may then admit two varieties of appendicitis: 
a traumatic appendicitis, the perforation being due to 
direct traumatism by a pointed body, and a stercoral 
appendicitis — grouping under this head all the cases 
where the lesions are in relation with the presence of 
round foreign bodies of which the stercoral concretion 
is the most common instance. 

This distinction between foreign bodies and the 
faecal concretion has in fact no interest except from 
an etiological point of view. Abstraction being made 
of pointed bodies which act by simple traumatism, 
the mode of action of smooth or round bodies, 
whether we have to do with scybala, seeds, or calculi, 
is always the same. It is none the less important to 
remember that the coprolith represents in the vast 
majority of cases the real offending body in appendi- 
citis. It is important then to understand the mode 
and place of formation of these faecal concretions. 

1. Origin of scybala. — Scybala are little balls of 
faecal matters more or less hard, having the aspect, 
the form, and the size of rabbit's dung. They have 
a brownish color and a variable consistence, being 
softish at first, hard when they are dried and old. 
Chemical analysis gives the same composition as that 
of faecal matters in the large intestine. 



It is generally admitted that they are formed in 
the caecum, some, however, insist on their formation 
in the appendix. — Faecal matters penetrate the appen- 
dix in a liquid state and solidify on drying. This 
appendicular origin of scybala seems very doubtful. 
If these concretions are formed in the appendix, they 
would take its form by being moulded to its cavity. 
They ought then to present an elongated, cylindrical 
form like that of the duct itself. Now scybala in 
general, and such as are found in cases of appendi- 
dicitis, are perfectly round. In order that they may 
take this spherical form, it is necessary that the par- 
ticle of faecal matter which constitutes them should 
by a process of kneading, rolling, mashing, be worked 
into that shape by the movement of the intestine 
in a rather spacious cavity. The cul-de-sac of the 
caecum alone offers the necessary disposition for this 
moulding. 

In my opinion the place of formation of scybala is 
always the caecum. The particles of matter detached 
from the faecal bolus or deposited in the anfractuosi- 
ties or hernias of the coats (Cruveilhier) which are so 
easily produced between the longitudinal bands of 
the muscular layer, take the form of these depres- 
sions, then being detached from their primary nest 
they become round, like bullets under the finger, during 
the peristaltic movements of the intestine in contact 
with the resistant plane furnished by the contractions 
of the caecal parietes. 



3 3 



It is possible, moreover, that in long and large ap- 
pendices, such as are sometimes seen, there may be 
formed by the same mechanism little faecal concre- 
tions, but by the very reason of the largeness of the 
canal they have no importance and cannot play any 
pathogenic role. 

2. Mode of action of the concretions. — The patho- 
genic role of scybala and of concretions has not 
escaped the different writers who have observed the 
perforations of the appendix-vermiformis. But on the 
one hand the role which they assign to them is lim- 
ited to that of agent of the perforation; on the 
other, they do not indicate how the concretion could 
produce ulceration of the walls. They content them- 
selves with saying that the perforation of the appen- 
dix is in general caused by a stercoral concretion or 
a foreign body, and they as much as intimate that the 
scybala or fruit stones, etc., determine directly the 
traumatism of the walls after the manner of a pin or 
a fish bone. 

But how can we explain how a soft and round body 
like a scybalum can act upon the walls of the appen- 
dix like a pointed body or one furnished with sharp 
angles? How explain why the entire appendix should 
be swollen, dilated, inflamed, thickened and in pro- 
cess of gangrene? How also does it happen that in 
most cases the perforation is not seated in the vicin- 
ity of the foreign body, but some little distance be- 
low it? 



— 34 — 

I have repeatedy stated my objections to this theory, 
and ten years ago proposed the following interpreta- 
tion of the lesions of appendicitis and of the mode of 
action of faecal concretions, as well as of fruit stones, 
gall stones, and other round concretions which may 
obstruct the appendicular canal. 

The foreign body, of whatever nature, being sud- 
denly engaged in the appendix by the inordinate 
contractions of the caecum, penetrates by effraction 
and lodges in the upper part of the duct. Two conse- 
quences take place: obliteration of the orifice of com- 
munication between appendix and caecum, compression 
of the walls of the appendix and obstruction of the 
circulation in the vessels contained in its walls. 

From obliteration of the orifice result the accumu- 
lation of the products of glandular secretion of the 
mucosa and distention of the appendix; from the 
■compression of the vessels, the diminution of vitality 
of the organ. 

The microbes which exist in permanence on the 
surface of the mucosa, pullulate and multiply in the 
stagnant liquid of the closed appendix as in a tight 
vase. These microbes, inoffensive in the normal 
state and impotent against the healthy elements, 
triumph without difficulty over those elements when 
deprived of their nutrient blood; they multiply with- 
out stint, inflaming, destroying and ulcerating the 
walls of the appendix, and by one or more points, end 
by perforating them and making irruption into the 
peritoneum. 



— *5 — 

Such, in my judgment, is the mechanism of per- 
forations of the appendix, and apart from trau- 
matic perforations by pins, fish bones, and other 
pointed bodies, and other rare perforations due to 
specific ulcerations (tuberculous, typhoid, or cancer- 
ous) I believe it is the ouly possible explanation. 

What about the cases (about one-third, according 
to statistics,) where no foreign body is found in the 
appendix at the autopsy or laparotomy ? 

In many cases, the omission to mention the pres- 
ence or absence of a foreign body may have been 
due to neglect to look for any. Such negligence 
has been sufficiently common in the past. In other 
instances three alternatives are possible: Either 
the foreign body, half engaged, and fixed only at 
the superior part of the appendix, falls back into 
the caecum, the tension of the walls which keep 
it in place, giving way at the moment of perforation; 
or else, in contact with the liquids accumulated in 
the duct, the scybalum becomes softened and trans- 
formed into a semi-fluid mass, grayish or greenish, 
such as has been noticed in several cases where such 
a liquid has been seen to exude on pressure from 
the seat of perforation; or, finally, the faecal concre- 
tion is discharged into the peritoneum or peri-csecal 
abscess, where, if the affection is prolonged, it be 
comes dissolved and disappears, but where it will be 
found perfectly recognizable when the opening of the 
purulent collection is made early. In nine observa- 



— 36 — 

tions of Roux, of Lausanne, where the presence of a 
scybaluin was noted at the opening of the abscess, in 
five the concretion was in the cavity of the appendix, 
while in four it was in the evacuated pus. As for 
this displacement of the scybalum, it is attested by 
autopsies which show the foreign body engaged in 
the opening of the perforation, or completely escaped, 
and still in contact with the external wall of the ap- 
pendix. 

Another objection may be made, the presence 
sometimes noted of scybala or foreign bodies in the 
cavity of an appendix absolutely healthy. The most 
remarkable case is that of Lewis; at the autopsy of 
a man aged 88 years, a great lover of game, who, 
during his life, had never presented any symptom of 
appendicitis, there was found in the appendix 122 
small shot. 1 

But this objection is precisely the justification of 
this theory which we advocate. Foreign bodies, scy- 
bala, etc., are incapable of themselves of provoking 
inflammation of the appendix; as long as they are 
free in its cavity they are inoffensive. No more in 
the appendix than in the caecum, is it likely that the 
simple contact of faecal balls can inflame a mucosa 
made to be in perpetual contact with faecal matters. 
In order that an inflammation may be produced, it is 
necessary that the foreign body should obliterate the 
duct and compress its walls. 

i N. Y. Med. Jour., 1856. 



10. The Microbes and Their Role. 

In fine, the scybala or roundish concretions which 
are found in the cavity of the appendix, cannot be 
regarded as direct causes of irritation or perforation; 
they are agents of obstruction and of compression. 

The mechanism of compression is not just what Dr. 
Porter, of Boston, thinks it to be. His idea is 
that the pressure exercised by the foreign body 
on the vessels of the walls leads to gangrene of these 
walls; but according to him, perforation takes place 
at the line of demarcation which separates the sound 
from the sphacelated parts, i. e., above the concretion. 

To this, Roux, of Lausanne, objects that in a good 
many cases the perforation is below the foreign 
body. He adopts the view of obstruction. The 
occlusion of the duct gives rise immediately to a 
more intense secretion of the mucosa, to an engorge- 
ment of the walls w r hose vessels are compressed at 
their point of entrance. These walls become rigid, 
less elastic; they become gangrenous, in whole, or 
in part, if the calculus is angular or if it compresses 
largely all the vessels; but the perforation may take 
place under the action of the pressure of the pent up 
liquid of the appendix, and is not necessarily limited 
to the point of strangulation of the calculus, which 
acts in many cases like a simple plug, less often as 
the immediate agent of the perforation. 1 



1 Roux, of Lausanne, Surgica 1 Treatment of Suppurative Perityphl- 
tis, Rev. Med., de la Suisse Ronmnde, April, 1890. 



— 88 — 

This hypothesis of the rupture of the appendix by 
the internal pressure of the liquids does not seem to 
me to be tenable. The extensibility of the intestinal 
walls is considerable; there would be needed in order to 
overcome it an enormous pressure which we cannot 
reasonably ascribe to the liquid secreted in the appen- 
dix; at any rate, if this tension were sufficient to cause 
rupture of the walls, for a stronger reason it should 
be sufficient to force back into the caecum the foreign 
body and thus clear away the obstruction. If, then, 
neither compression nor obstruction can of itself 
explain the ulcerous process or the perforation, we 
need the intervention of a third factor sufficient to 
cause the destruction of the anatomical elements of 
the wall, namely the bacterial proliferation in the 
interstices of tissues which have lost by suppression of 
their nutrient blood, a part of their vitality. 

This active role of microbes I pointed out 10 years 
ago in my communication to the Anatomical Society. 
No one to-day contests it. We do not at this day 
need the aid of culture and other experiments to 
prove this. It is evident that no specific microbe 
presides over the perforations of the appendix. We 
may nevertheless ask if some one of the species which 
inhabit the surface of the intestinal mucosa does not 
take a predominant part in the evolution of the 
lesions. 

Unhappily, the microbiology of the intestine is so 
difficult and obscure, the few notions that we possess 



— :}fl — 

on this subject are still so confused, that we can make 
no precise affirmation as to the role attributable to 
the different species in the intimate mechanism of 
appendicitis. Numerous varieties of coccus, of bac- 
illi, of vibriones, without reckoning the fungi of 
higher order, saccharomycetes, mucedinse,vegetate, in 
the normal state, in the intestinal mucus. In certain 
pathological states, some of these species seem to 
take on a predominant development which enables 
us more easily to isolate them by culture. Thus it 
is that we know the Neapolitan bacillus of Emmerich, 
found in the cholera epidemic of Naples, the curved 
bacillus of Finokler and Prior, isolated in cholera 
nostras, the bacillus of green diarrhoea of Clado and 
Lesage. But we do not know if these microbes 
naturally belong to the intestine or if they come 
from without. We do not know even if they consti- 
tute distinct species, as the bacillus of Emmerich does 
not seem to be other than the bacterium coli com- 
mune, and there are some that think that the bacter- 
ium coli is itself only the attenuated typhoid bacil- 
lus. The morphological differences are inapprecia- 
ble, since the species are themselves polymorphic, 
and the differences of culture are so slight that 
scarcely a differential character is attributed to one, 
before we are obliged to admit that the others pos- 
sess it also. So in the end what really characterizes 
them the best is the name of their discoverer and the 
pathological state where they are ordinarily met. 



— 40 — 

It is plain tbat in these conditions it would be use- 
less to try to recognize them in the contents of a normal 
intestine. There exists, however, a species which 
seems really autonomous, it is that which Escherich 
has described under the name of bacterium coli com- 
mune. 

It is a polymorphous bacterium of variable length, 
mobile, and presenting in its development in divers 
media such similarities to the typhoid bacillus that 
Roux and Rodet, of Lyons, see in these two organ- 
isms only the same species under different forms with 
different degrees of virulence. 

This bacterium is found in the normal state in the 
mucus of the large intestine. In four cases of choler- 
iform diarrhoea in man, Gilbert and Girode have 
isolated and collected it, not only from the stools and 
intestinal liquids but also from the urine, from the 
pleura, from the lungs, and from the cephalo-rachi- 
dian liquids. The same observers, as also Charrin and 
Roger, have found it in suppurative angiocholitis; 
Yeillon and Jayle have detected it in an abscess of 
the liver of dysenteric origin. According to these 
writers, the bacterium coli can then produce not only 
inflammatory lesions but also suppuration. 

It might have been foreseen that the same mi- 
crobe would be found in the exudation of peritonitis, 
Laruelle was theiirstto declare that it is the veritable 
agent of peritonitis by perforation. He admits, 
neverthless, that a prior alteration of the serosa is 



— 41 — 

necessary whether by contact with the bile, whether 
by contact with the intestinal liquid, in order that 
the inflammation may be produced. 1 

A. Frankel, in 31 cases of peritonitis, has met the 
bacterium coli in six, and in two another bacterium 
described also by Escherich in the stools of new-born 
infants, the bacterium lactis aerogenes which Babin- 
sky proposes to name bacterium aceti by reason of 
the great quantity of acetic acid w T hich it produces in 
fermenting the sugar of milk. 2 

In four cases of peritonitis by perforation, Bar- 
bacci found the bacterium coli not only in the peri- 
toneal exudation, but also in the blood, of the heart 
and blood vessels. 

Dr. William H.Welch has noted the presence of the 
same microbe in six cases of peritonitis; in four the 
peritonitis was due to perforation; in two it was con- 
secutive to an intestinal affection without perfora- 
tion. However, W x elch does not seem to be con- 
vinced of the phlogogenous action of the bacterium 
coli on the serosa. He says that in intestinal diseases 
this bacterium has a great tendency to diffusion 
throughout the organism. In 25 autopsies of persons 
who had died of intestinal lesions, ulcerations, diph- 
theritic or hemorrhagic inflammations, traumatisms, 
he has isolated it in pure cultures from most of the 



J Laruelle, Bacteriological study of peritonitis by perforation, La 
.Cellule 1889, t, v. 

2 A. Frankel, Wiener Klin. Woch., 1891, Nos. 13 and 15. 



— 42 — 

viscera; he has hardly ever met it outside the intestine 
when the mucosa was sound. He does not then think 
it to be demonstrated that the bacterium coli poss- 
esses a pathogenic role apart from certain special con- 
ditions. 1 

Lastly, in a recent paper embodying personal re- 
search, Malvoz says that in six cases of peritonitis of 
intestinal origin he has always found the Escherich 
bacillus in a state of culture almost pure. In one 
case he had to do with general fibrino-purulent peri- 
tonitis consecutive to appendicitis. Malvoz did not 
determine whether there was perforation. Cultures 
made with the peritoneal exudate and with, the blood 
of the heart gave the bacterium, coli to the exclusion 
of every other microbe. 

These facts prove the frequency if not the con- 
stancy of the bacterium of Escherich in the exudate of 
peritonitis of intestinal origin. The observations of 
Malvoz and Welch show that it is not necessary that 
there shall be perforation in order that this microbe 
may penetrate the peritoneum. It seems tLen that 
we may conclude that the presence of the bacterium 
coli characterizes these peritonites just as the pres- 
ence of the streptococcus characterizes puerperal per- 
itonitis. 

But is the coli commune capable of itself of pro- 



1 Conditions Underlying the Infection of Wounds, A.m. Jour, of Med. 
Sc. Nov. 1891. See also Wurtz and Hermann in Arch, de Med Experim 
Nov, 1891. and Widal's article on the bacillus coli in Qaz. hebd. de Med.. 
Jan. 1892. 



— 4;} — 

voking inflammation of the serosa? The experiments 
of Laruelle and Frankel seem to indeed establish that 
peritonitis is not produced after the injection of pure 
cultures of the microbe, unless one at the same time 
injects bile or sterilized intestinal liquid. In human 
pathology these conditions are realized when there is 
a perforation; the bacteria fall into the peritonaeum 
with the liquid which contains them. But in peri- 
tonitis by propagation, how are we to explain the 
phlogogenous action of the bacterium colif Charrin 
and Roger nevertheless say that they have caused by 
intra-peritoneal injections of this microbe, hemorr- 
hagic peritonitis which killed the guinea pigs in 15 
days. Widal says also that hy inoculating in the 
peritonaeum of guinea pigs minimum quantities 
of fresh cultures, he has induced fibrinous peritonitis 
with a fall of temperature and rapid death of the ani- 
mals. New researches evidently are necessary to 
establish definitely the mode of reaction of the peri- 
tonaeum in presence of the coli commune. 
Is this microbe now the sole cause? In two cases of 
peritonitis consecutive to tuberculous ulcerations of 
the intestine, Frankel has found the streptococcus 
pyogenes; in two other cases, of intestinal origin, he 
has isolated the bacterium lactis aerogenes; lastly in 
one case there existed several microbic species asso- 
ciated. In a case of perforative appendicitis, Welch 
says that streptococcus pyogenes seemed to be the 
only organism present in the peritoneal exudate. It 



_ 44 — 

is probable that more minute researches will reveal 
other varieties of micro organisms. 

We do not, then, feel justified in regarding the 
bacterium coli as the sole pathogenic agent of the 
peri appendicular lesions. It characterizes by its 
presence the exudate of appendicular peritonitis; but 
it is probable that other intestinal microbes may be 
associated with it, as the golden staphylococcus, enter- 
ing with the food and escaping the action of the 
gastric juice, and it may be that in certain cases 
some one of these may take the ascendency, and by 
its predominant proliferation modify the aspect and 
the consequences of the intestinal perforation. 

11. Lesions of the Walls of the Appendix. 

This pathogenic role of foreign bodies and of mi- 
crobes enables us to interpret not only the grave 
forms of appendicitis with gangrene and perforation, 
but the milder forms as well. 

It is evident that the foreign body may be more or 
less voluminous and the canal more or less narrow. 
The degree of constriction exercised on the vessels of 
the walls will vary, then, according to these two con- 
ditions, and consequently the circulation will be sim- 
ply impeded or retarded, rather than obstructed; 
hence there will be degrees also in the damage done 
to the vitality of, the walls. 

On the other hand, the liquid imprisoned in the 
appendix may be more or less rich in microbes, and 



more or less favorable to their development. Doubt- 
less also, we must take account of the kinds of bac- 
teria found in the appendix at the moment of the 
obstruction, of their pathogenic power and degree of 
virulence. 

Lastly, the foreign body may become displaced; it 
may fall back into the caecum, whether by reason of 
peristaltic contractions of the muscular coats of the 
appendix and large intestine, or from softening of 
the periphery of the scybalum in contact with the 
secretions of the duct. 

These alternatives explain the variable intensity 
of the inflammatory process, which may be limited 
to simple exudative inflammation of the walls, an 
inflammation that may be propagated to the external 
cellular and peritoneal coats, and which may finally 
end in limited perforation or total gangrene of the 
appendix. 

These are not theoretical lesions like those of the 
classics typhlitis; they are lesions which have been seen 
and noted many times. The post-mortem examination 
gives only the grave lesions of perforative appendicitis, 
but the daring laparotomies of the American surgeons 
have enabled us, so to speak, to watch the successive 
stages in the living subject, and to follow all the 
other phases and modalities which do not ordinarily 
end fatally. It is on the numerous observations pub- 
lished the last five or six years in England and es- 
pecially in America, that the following description is 
based. 



— 46 — 

From an anatomopathological point of view, we 
may admit three principal varieties of appendicitis; 
simple appendicitis acute or chronic, suppurative ap- 
pendicitis, and gangrenous appendicitis. 

a. Simple inflammatory lesions. — These correspond 
to what the Americans call acute or chronic catarrhal 
appendicitis. This term is, in my judgment, im- 
proper, in that it seems to indicate a superficial 
phlegmasia limited to the mucosa, when in reality all 
the coats are affected. It is theoretically possible 
that in the mildest cases, in appendicular colic of very 
short duration, the lesions may be limited to a tem- 
porary irritation of the mucosa, but this can neither 
be affirmed nor verified, as the accidents all appear 
and disappear in 24 hours. The name of parietal ap- 
pendicitis seems to me to be preferable. 

The earliest operations practiced for appendicitis 
occurring in a light form, have been made on the 
second or third day after the onset of the disease. 
Already at this period there exists a roughness, a want 
of polish of the serosa, and soft adhesions between 
the appendix and surrounding parts. The inflamma- 
tion starting in the mucosa spreads with great rapid- 
ity through all the coats of the appendix, and reaches 
the peritoneal coat in 48 hours. This is the import- 
ant fact to remember. 

The appendix is augmented in volume; it appears 
dilated, turgescent as in erection, and is as large as the 
little or index finger, its walls are thickened, its cavity 



— 47 — 

is enlarged and tilled with a viscous or semi-purulent 
mucus. 

The microscopical examination shows the vessels 
of the mucosa and submucosa to be dilated and en- 
gorged with red blood globules; the cul-de-sac of the 
tubular glands filled with large cells; the interstitial 
tissue tilled with embryonal cells. This infiltration 
is continued between the fibres of the muscular layer; 
it then spreads to the sub-serous coat under a diffuse 
form or by little masses of round nuclei. The endo- 
thelial cells of the serosa are in part desquamated or, 
it may be, augmented in volume, containing vacuoles 
or granulations. 

Such lesions may surely end in resolution without 
leaving any traces, as those cases seem to indicate 
which get well by simple medical treatment. They 
may also be the first phase of the process of suppu- 
ration to which we shall return presently. Lastly, 
without completely resolving, they may pursue a 
chronic course. 

With regard to this chronic evolution, is it always 
consecutive to an acute attack ? May it not be 
chronic from the first? This is probable, and in such 
cases we may ask if the appendicitis is not an epi- 
sode of a chronic lesion of the large intestine, and if 
the catarrh of the mucous membrane of the colon 
has not been propagated to that of the appendix? 
This is an etiological question which awaits discus- 
sion. 



— 48 -- 

However this may be, the simple chronic appendi- 
citis which oftenest forms the anatomical substra- 
tum of the clinical variety called relapsing appendi- 
citis, or at least which often constitutes the sole les- 
ion on excision of the appendix in the interval of 
two attacks, presents itself under divers aspects. 

In general, the appendix is augmented in volume; 
its external surface is rugous; its walls are indurated 
and hypertrophied; it is adherent by some point to 
neighboring coils of intestines, to the abdominal 
wall, or to the omentum; sometimes it is imbedded 
in a mass of fibrous tissue and difficult to detach. 
The cavity is dilated and contains several drops of 
thick mucus. The mucosa appears smooth and 
healthy. 

In two cases reported by Porter, 1 the microscopic 
examination showed no alteration of the mucous mem- 
brane, the chronic inflammation occupied exclusive- 
ly the submucosa, the muscular and peritoneal coats. 

Apart from a certain degree of dilatation, the cavity 
of the appendix may then be normal. At other 
times, it presents partial contractions with dilatations 
above and below, sometimes even a complete obliter- 
ation which divides the canal into two, the free 
extremity being then extremely thickened, dilated 
and distended by mucus. Lastly, the obliteration 
may be total, the appendix being reduced to a hard, 
fibrous cord, lost in the midst of fibrous adhesions. 



Porter. Boston Medical and Surgical Journal, Dec. 25, 



— 49 — 

h. Suppurative lesions. — The liquid contained in 
the inflamed duct is almost always purulent; in sub- 
acute appendicitis, if the upper orifice is obstructed, 
there will be a little purulent collection pent up in the 
cavity. The true, suppurative appendicitis is where 
the parietal inflammation determines the formation of 
little masses of pus between the coats of the appen- 
dix. Ordinarily, when the surgeon operates, he finds 
the appendix in its entirety infiltrated with pus and 
generally perforated. 

c. Gangrenous lesions. — These are the most im- 
portant and the most common. The greater the con- 
striction exercised by the foreign body, and the 
nearer this is to the base of the appendix, the more 
rapid and complete the necrosis. In a case reported 
by Dalton, of St. Louis, the operation performed just 
24 hours after the onset of the attack, showed the 
appendix to be of a dark blue color, almost black, 
largely distended, and as large as the little finger, 
There was even then no inflammation in the vicinity; 
the appendix was not perforated; in its cavity was 
found a large and very hard concretion. 

The circulatory strangulation has then for its 
first effect venous stasis with oedematous infiltration 
of the walls. The two grave consequences of this 
first phase are limited perforation, or total sloughing 
of the appendix. 

In both cases the process is the same; partial, when 
the perforation is limited, general and circulatory 



— 50 — 

when the appendix is detached in its totality. The 
gangrene is a moist gangrene, a destruction by micro- 
organisms of the elements of the walls deprived of 
their vitality. 

Sometimes the perforation is single; sometimes 
there are one or several points of perforation, some- 
times the orifice is very small, difficult to find and 
scarcely visible; habitually it is clean cut, round, of 
the size of a hemp seed or of a pea. 

The seat of these perforations is never or scarcely 
ever in direct relation with the foreign body im- 
prisoned in the appendix; ordinarily, it is some little 
distance above or below / the concretion, very often 
near the point of the appendix. The perforation is 
simply in relation with the degree of vital resistance 
of the wall, and takes place just where this wall 
yields most rapidly to the destructive action of the 
microbes. Generally, an acute general peritonitis 
follows the perforation, carrying off the patient in a 
few days. But if the peritonitis is limited, the pro- 
cess of gangrenous ulceration has time to go on, the 
destructive action may involve the entire circum- 
ference of the appendix, which becomes detached in 
its entirety and falls into the pus cavity; this is total 
necrotic amputation. 

The appendix is then found in the purulent focus 
in the midst of pus and false membranes, sometimes 
easy to detect, under the form of a cylinder more or 
less long, of greenish gray or blackish color, infil- 



— 51 — 

ated with purulent liquid, sometimes unrecognizable 
and confounded with pseudo-membranous shreds and 
the debris of the sphacelated connective tissue. 

12. Peri-Appendicular Lesions. 

The appendix cannot be seriously affected, as has 
been seen, without rapid diffusion of the inflamma- 
tion through the various coats till the external coat 
is reached. There is no appendicitis without more 
or less of peri-appendicitis, but the gravity and the 
extension of the peri-appendicitis-lesions are them- 
selves variable, as the intensity of the parietal lesions. 

It is important first to determine the habitual seat 
of these lesions. The old pathologists saw only les- 
ions of the sub-peritoneal connective tissue, while 
most surgeons at the present day think that the con- 
nective tissue is only exceptionally involved, the 
almost constant peri-appendicular affection being 
peritoneal inflammation. 

An absolute affirmation is no more permissible in 
the one case than in the other. It cannot be denied 
that the sub-peritoneal cellular tisssue may be in- 
vaded, at least secondarily to the peritonitis, in those 
prolonged cases where all the tissues of the iliac fossa 
down to the bone are found infiltrated with a puru- 
lent and sanious bouillie. 

But direct inflammation is also possible. Anatom- 
ical investigations show that out of 200 cases, in 123 
the appendix is free in the peritoneal cavity, but in 



— 52 — 

11 it is in intimate relation with the subperitoneal 
tissue (Ferguson). It must then be admitted that if 
appendicitis were to supervene in one of these 11 
cases, the peri-appendicitis would be not a peritonitis 
but a phlegmon. It may then w T ell be believed that 
in a certain number of cases the inflammation pri- 
marily affects the retroperitoneal connective tis- 
sue. At the same time such cases are admittedly 
exceptional. Their possibility however must be kept 
in mind. The statistics given by writers certainly do 
not prove the constancy of peritonitis, whether enbys- 
ted or limited. In 100 autopsies, were found 85 
peritonites, four extra peritoneal abscesses, . and 11 
complex cases. Maurin in 94 cases of fatal appendi- 
citis, found 80 peritonites, five extra peritoneal ab- 
scesses, and nine cases where there was at the same 
time abscess and peritonitis. Even in the fatal cases, 
the abscess may then exist alone in the proportion of 
five per cent., but naturally the fatal cases are for 
the most part due to a peritoneal perforation. In 
cases which have recovered, however large may be 
the part which we assign to encysted peritonitis, is it 
not right to suppose that for a certain number the 
inflammation is localized in the cellular tissue ? 

We admit then the possibility of peri-appendicitis 
of the cellular tissue which may sometimes end in 
resolution, but may also become the origin of a peri- 
cecal abscess. But this being granted, we must 
recognize two things: 1. That pathological anatomy 



— 53 — 

is incapable of describing the first phases of this 
type; 2. That peritoneal lesions of whatever nature 
are incontestibly more frequent. 

These lesions may be simply plastic — -fibrinous or 
adhesive peritonitis; or fibrino-purulent, suppurative 
peritonitis; or sero-purulent sero-sanguinolent, with 
fetid odor, septic peritonitis. They may be diffuse 
and general, or partial, limited, and encysted. Lastly, 
they may be produced by propagation by continuity 
and contiguity through the walls of the appendix, 
progressive peritonitis, or by rupture of the divertic- 
ulum, pjeritoiiitis by perforation. 

a. Partial jibrino-plastic peritonitis. — When the 
lesions are limited to a fibrinous exudation, the peri- 
tonitis is always progressive; the peritoneal inflam- 
mation takes place in contact with the appendix, just 
as fibrinous pleurisy in contact with a focus of pneu- 
monia. The fibrinous peritonitis belongs to simple 
appendicitis or at least to the first phases of the 
appendicitis as long as perforation does not take 
place. It may be sufficiently marked at the end of 
36 to 48 hours to produce adhesions between the 
appendix and the neighboring parts, and to glue 
together coils of the intestines. This first outbreak 
of peritonitis may be more beneficial than injurious; 
it has no tendency to spread far, and in provoking 
the formation of adhesions, it limits the consequences 
of the perforation; if the latter takes place, it pre- 
vents the escape of irritant matters into the abdomen; 



— 54 — 

the suppuration remains encysted in the space cir- 
cumscribed by the plastic exudation. 

But the perforation may not take place. What 
then becomes of this partial peritonitis? Does it 
remain fibrino-serous, or may it suppurate? I am led 
to believe that suppuration does not take place unless 
the appendix is perforated. It is not however im- 
possible that the pyogenic microbes may under some 
circumstances, as an event of their proliferation, pass 
through the walls of the duct without causing ulcera- 
tion. This is however still a matter of hypothesis. 

The rule is that the peritonitis remains iibrino- 
serous if the appendix is not perforative. You will 
find, on opening the abdomen, coils of intestines agglu- 
tinated, matted together, by a fibrinous reticulum con- 
taining in its meshes an opaque serosity of fetid 
odor. It would be interesting to make the micro- 
biological examination of this liquid, and to deter- 
mine the species of microbes, if any, that are found 
there, and whether in fact the -effusion is in direct 
relation with the presence or absence of micro-organ- 
isms. A few years ago we should not have hesitated 
to affirm that the absence of two pyogenic microbes, 
the staphylococcus aureus, and the streptococcus-pyo- 
genes, would explain the non-suppuration of the exu- 
dation. To-day, most of the pathogenic microbes 
seem capable of producing pus; we do not know 
exactly what suppuration is, and we should be chary 
of hypotheses. 



What is certain, is the persistence in the fibrinous 
state of the encysted exudate. And what from a 
practical point should be remembered, is that this 
local fibrinous peritonitis gives rise to the same phys- 
ical signs of puffiness, tumefaction, and dullness, as a 
purulent collection. 

The surgeon finds here a new reason for hesitation 
when deliberating about an operation. For there is 
no doubt that this fibrinous exudate may resolve and 
be absorbed like every other exudate of the same 
nature, pleuritic or pericardiac, and that this resorp- 
tion explains the great number of perityphlites cured 
medically without the aid of the surgeon. 

Another consequence attending this peri- appendic- 
ular peritonitis, is the fixation of the point of the 
appendix in a position and in regions absolutely 
abnormal. When it is free in the abdomen, the ini- 
tial inflammatory attack may fix it and make it adhere 
in points where we should not expect to .find it, the 
rectum, the bladder or the vagina. The appendix has 
even been found in the scrotum in a hernial sac, or 
fastened to the anterior wall of the abdomen near the 
umbilicus. If perforation takes place under such 
conditions, the seat of the encysted peritonitis will 
not be the iliac fossa where it is ordinarily located, 
and you can see how difficult it would be to diagnos- 
ticate an appendicitis when you have a fluctuating 
tumor of the scrotal or umbilical region. 

b. Encysted purulent peritonitis. — This is the ordi- 



— 5G — 

nary anatomical form of perityphlitis, of the peri- 
cecal abscess; it is the most common consequence 
of perforative appendicitis, on condition that the 
initial peritonitis has had the time to form protective 
adhesions, or that these adhesions existed previously, 
the remains of a former appendicitis. It is on the 
position of the appendix in the abdomen that the 
seat of the purulent collection depends. 

c. General peritonitis. — If previous adhesions do 
not exist or if the adhesions are not sufficiently re- 
sistant, if the perforation takes place rapidly in the 
first 48 to 12 hours, the peritonitis is general from the 
first. But a diffuse inflammation of the peritonaeum 
may come on later and be secondary. The perfora- 
tion will first give rise to an encysted collection, then 
at the end of a variable time, whether by rupture of 
the sac or by propagation of lesions at first localized, 
the inflammation becomes generalized to the whole 
serosa. 

The morbid changes are the same in both cases: 
agglutination of the intestinal coils, which are cov- 
ered with vascular purplish arborizations; false mem- 
branes accumulated in certain points, most abundant 
in the right iliac fossa, fibrinous or infiltrated with 
pus; a turbid, more or less opaque liquid containing 
fibrino-purulent flakes, having- a special fetid odor, 
sometimes a frank stercoral odor; in some cases the 
presence of gas in the abdominal cavity. 

I shall not return to what I have said concerning 



microbes found in such cases in the exudate. The 
presence of the bacterium coll is probably constant, 
but is this bacterium the true cause of the peritoneal 
inflammation? As it is associated with several other 
varieties, what is the part which belongs to it, both 
in the septic and phlegmasic accidents? It is probable 
that the lesions are not absolutely identical in all 
cases, and that the quality of the exudation differs 
according to the bacterial species whose development 
predominates. It is certain that the abundant form- 
ation of liquid pus which results from the presence of 
the puerperal streptococcus in the peritoneum of lying- 
in-women is not observed in peritonitis by perfora- 
tion of the appendix; but perhaps, also, it is only a 
question of duration, the peritonitis by perforation 
killing much more rapidly than puerperal peritonitis. 
However this may be, the facts show that certain 
peritonites by perforation are surely rather septic 
than inflammatory. They cause death much more 
promptly in three or four days, with the symptoms 
of septicaemia, of adynamia, without marked febrile 
reaction. The exudation in these cases is turbid, 
sero-sanguinolent, with disagreeable odor, rather than 
frankly purulent. Perhaps these septic peritonites 
are more especially in relation with the bacterium 
coli, and there may be associated with it some of 
the vibriones which are met with on the surface of 
the intestinal mucosa. 



58 



13. The Perityphlitic Abscess. 

The purulent collection consecutive to perforation 
of the appendix is generally, as we have said, intra- 
peritoneal. But in a certain number of cases it may 
be sub peritoneal, occupying the retro caacal and iliac 
cellular tissue. This is what the old writers called 
abscess of the iliac fossa. It is to-day, however, in- 
disputable that the extra-peritoneal seat of suppura- 
tive perityphlitis, which they regarded as most com- 
mon, is the most rare. 

The contents of the purulent sac would suffice of 
themselves to demonstrate the peritoneal origin of 
the pus. It is, in fact, exceptional to find the pus 
thick, of good consistence, like the pus of a phleg- 
monous abscess of the cellular tissue. It is ordinarily 
thin, turbid, opaque or greenish, full of flakes or of 
debris of false membranes, being a purulent serosity 
rather than true pus. 

This liquid has a fetid, sometimes faecal, sometimes 
almost gangrenous odor, which may infect the room 
during the operation. The presence of gas in the 
purulent sac is frequent. In this pus may be found 
fragments of faecal matters hard or soft, little round- 
ish scybala from the perforated appendix. 

The limits and dimensions of the purulent collec- 
tion are very variable. From a tumor as large as 
the fist limited to a point of the iliac fossa, to the 
diffuse and gangrenous infiltration of all the poster- 



— 59 — 

ior abdominal region, we may observe all degrees. 
In explanation of this fact, we must take account of 
the duration of the disease, and distinguish between 
the results furnished by the post mortem examina- 
tion when the course of the abscess has been left to 
itself, and cases where the bistoury has stopped the 
extension of the lesions, and where the autopsy is, so 
to speak, surgical. 

In cases of the first kind, the opening of the 
cadaver will show the extreme alterations described 
by Grisolle in phlegmonous tumors of the iliac fossa. 
In cases of the second kind, the size and the seat of 
the purulent collection will present notable differ- 
ences. These differences of location are determined 
by the variable position which the appendix occupies 
in the abdominal cavity. 

Sometimes the appendix takes a downward direc- 
tion, and its perforation will give rise to a purulent 
collection in the inferior part of the iliac fossa; the 
pus will accumulate above Poupart's ligament; the 
abscess will be intra-peritoneal or sub-peritoneal or 
both, according as the appendix is free, or according 
as it is fixed by its mesentery to the iliac fossa; the 
perforation takes place between the folds of this 
mesentery, in the cellular tissue communicating with 
the sub-peritoneal tissue. In these conditions, the 
abscess will point in the groin, and if left to burst, 
may leave at this point a fistula which may persist 
for months and even years. Fitz has seen a patient 



— 60 — 

in whom a fistula of this kind had lasted more than 
19 months. 

2. Sometimes the appendix is directed inwardly 
and engages in the pelvis, and comes into relation 
with the anterior aspect of the rectum. In cases of 
this kind, the peritonitis becomes encysted in the in- 
ternal part of the iliac fossa, and the pus tends to 
accumulate in the pelvis between the rectum and the 
bladder, or the vagina, in the female. By the rectal 
and vaginal touch, the purulent sac can be detected 
at this point. A spontaneous opening may take 
place in such cases, generally into the rectum, some- 
times into the vagina or bladder. 

3. Sometimes the appendix is inflected inwardly 
and anteriorly, being applied to the internal aspect 
of the caecum. In such cases, the pus may collect 
above and within the iliac fossa, and even point in the 
neighborhood of the umbilicus. It is probable that 
the cases of encysted suppurative peritonitis described 
in the infant as of spontaneous origin, and getting 
well after evacuation of the pus by the umbilicus, 
are only cases of appendicitis belonging to this third 
variety. 

4. Lastly the appendix may be situated behind the 
caecum glued to its wall, or embedded in the cellular 
tissue of the retrocecal region. In cases of this 
kind, the pus will collect around the caecum and 
point in the costo-iliac space, or in the lumbar region 
above the crest of the ilium. Whether it be at first 



— 61 — 

extra or intra peritoneal is of little consequence in 
such a case; the abscess behaves as if it were con- 
fined to the cellular tissue, isolation from the great 
peritoneal cavity being easily effected in this region. 
Limited in front by the large intestine, behind and 
at the side by the lateral and posterior wall of the 
abdomen, the abscess, by reason of the thickness of 
the muscular layers which it would have to perfor- 
ate, has little tendency to burst externally. Either 
it burrows downwards in the iliac fossa, or it extends 
upwards and may come into relation with the in- 
ferior surface of the liver, perforate the diaphragm 
and determine a purulent pleurisy, or even open into 
the csecum or colon. A large number of the cases 
reported as examples of primary ulcerous typhlitis 
determining a suppurative perityphlitis by perfora- 
tion of the csecum, are cases of inflammation of the 
appendix, thus deviated backwards, or outwards; the 
perforation of the walls of the csecum is the conse- 
quence and not the cause of the perityphlitic abscess. 

Such are the four principal types of localization of 
purulent collections consecutive to perforation of the 
appendix. Moreover, the sac is not always single, 
the peritonitis often walls in two or three spaces in the 
midst of false membranes, and these spaces form 
distinct pockets of pus. 

Besides the four principal localizations, iliac, pre- 
rectal, umbilical and lumbar, the peri-appendicular 
collection may gain regions where one would never 



— 62 — 

have thought of looking to the appendix for the origin 
of the abscess. Thus, an appendix has been known 
to be inflamed and perforated in a hernial sac 
(Shaw). Another rare variety is scrotal appendicitis 
(Thurman, Monks). 

When the abscess does not open either externally 
or internally; when surgical interference is not sought, 
or is sought too late; when, in a word, the patients 
succumb to exhaustion and septicaemia, there are 
found at the autopsy lesions which are sometimes 
extremely diffuse. 

Besides the abscess, more or less well localized, 
with blackish, irregular walls, forming the principal 
foyer, and containing a pus which is stercoral, fetid, 
gangrenous, we habitually note, on the one hand a 
peritonitis which is generalized and fibrino-purulent, 
and on the other an infiltration, more or less exten- 
sive, of the cellular tissue and of the muscles of the 
retro-peritoneal region. The psoas, iliacus, and quad- 
ratus lumborum have their fibres blackened, softened, 
and in part destroyed, dissected out by the putrid pus. 
Observers have seen at the end of three weeks, the 
peritoneum which lines the iliac fossa as well as 
the iliac fascia perforated and destroyed by the gan- 
grene, and the entire psoas muscle infiltiated with pus 
and sphacelated. 

Among the rare complications are: a, thrombosis 
of the iliac vein with oedema of the corresponding 
inferior member; b y a mortal hemorrhage may result 



— 08 — 

from ulceration of one of the arteries of the region; c, 
pylephlebitis is still one of the possible consequences 
of periappendicular abscess. Of the latter, Fitz has 
collected 11 cases out of a total of 257. 

This pylephlebitis may give rise to accidents 
which change completely the aspect of the disease, 
and in the midst of which the appendicitis disap- 
pears forgotten and misunderstood. From the throm- 
bosed mesenteric veins suppurative emboli are car- 
ried to the liver where they give rise to abscesses 
more or less formidable. Gendron has reported three 
cases of the kind where a voluminous hepatic abscess, 
consecutive to a pylephlebitis of appendicular origin, 
perforated the diaphragm, produced a pericarditis 
and a purulent pleurisy, which itself terminated by 
a vomica which opened into the bronchi. 1 



1 Vide Powell, New Orleans Med. and Surg. Jour., 1855, xi., 168.— 
Barlow, Lancet, 1853. 

Gendron. A Study of Suppurative Pylephlebitis. (Th6se de Paris 
1883). 



III. 



THE CAUSES. 



Pathological anatomy shows that in the immense 
majority of cases the true cause of the appendicitis, 
as far as being an isolated and independent affection, 
is the presence of a foreign body in the cavity of 
that organ. When the foreign body comes from 
without, a pin, a fish bone, a seed, a cherry stone, 
the etiology limits itself to noting that fact; the 
appendicitis is a simple accidental traumatic lesion. 
When the foreign body is from within, a scybalous 
concretion (stercoral appendicitis) we may undertake 
to investigate the conditions which put in operation 
this essential cause. We have then to study: 1, the 
causes which favor the formation of scybala; 2, the 
causes which determine its penetration in the appen- 
dix and provoke the accidents. 

14. Predisposing Causes. 

It is not easy to determine in what circumstances 
and under what influences scybala are formed. We 
must include under this head not only the causes 
which favor the formation of faecal concretions, but 
also, in a general way, the conditions in which 
appendicitis is generally observed. 

1. Atony of the large intestine. — The most com- 
mon cause alleged by writers is constipation. At 



— 65 — 

the same time, in 209 cases published under the name 
of typhlitis and peri-typhlitis and analyzed by Regi- 
nald Fitz, we find constipation 38 times mentioned 
in the antecedents of the patient, and in only 15 out 
of 257 cases of fatal perforative appendicitis was this 
fact indicated. This really gives little justification 
for the unanimity of the authorities in regarding 
constipation as the predisposing cause of the affec- 
tions. 

It is a little singular that constipation is so fre- 
quent in women, and at the same time appendicitis 
is four times more frequent in man than in woman; 
on the other hand, constipation is the rule in old 
people, and all the statistics show that appendicitis 
is very rare after the age of 40. 

Moreover, the statistics of Fitz show that out of 
466 cases, in 26 the subjects were affected by diarrhoea. 

It will hardly do, then, to say that either constipa- 
tion or diarrhoea favors the development of appendi- 
citis. Constipation and diarrhoea are of particular 
nature; they are the possible, though not certain 
effects of a functional trouble of the large intestine 
connected with those badly defined states called 
intestinal- atony, membranous-colitis, mucous-colitis. 
This bad functionating of the large intestine, charac- 
terized both by defective secretion of the mucosa and. 
by irregular, sluggish or unequal contraction of the 
muscular coat, manifests itself rather by dull pains 
in the belly, by abnormal tension of the abdomen, by 



— G«J — 

irregular stools, sometimes glairy, sometimes dry, 
than by a constipation or diarrhoea properly so-called. 

I believe that this chronic colitis is the most ordinary 
cause of f a±cal concretions. Matters fa j cal or mucoid of 
bad consistence are deposited in little masses in the 
culs-de-sacs and hernia? of the mucosa, become dried 
there and concreted in the form of little balls by the 
mechanism which I have indicated above. 

It may be objected that the recorded observations 
do not mention these intestinal troubles. But why 
be astonished at this? These troubles are too little 
marked ordinarily to be regarded as a disease, and 
the subject hardly thinks of consulting a physician 
about them, except when they end in a real and obsti- 
nate constipation, or severe attack of diarrhoea. 

It will also be objected that the autopsy ordinarily 
shows integrity of the mucous membrane of the 
large intestine. But we have to do with superficial, 
catarrhal lesions, which no more leave appreciable 
traces to the naked eye than a simple bronchitis or 
a coryza. 

These attenuated forms of glairy colitis are not 
rare in young people, they are especially observed in 
childhood, and are well known to the physicians of 
childrens' hospitals. In a recent work, Jules Simon 
has not failed to call attention to these preparatory 
intestinal troubles, and to indicate their role in the 
etiology of appendicitis in early life. 1 



1 Jules Simon, Rev. des mal cle VEufance, Oct. 1891. 



— 67 — 

2. Diet and previous diseases. — It is by the inter- 
mediation of this atonic-colitis that is explained the 
influence of diet or of previous diseases in the de- 
velopment of appendicitis. Great eaters are predis- 
posed to this affection; likewise undigestible, or too 
highly seasoned, or too nitrogenous a diet. But 
these dietetic vices are the most ordinary causes of 
chronic irritation of the large intestine. 

As for previous diseases, typhoid fever, eruptive 
fevers, dysentery, which are regarded as favoring ap- 
pendicitis, their role ought to be interpreted by 
the lesions which they have left after them on the 
mucosa of the colon, lesions which keep up the ten- 
dency to atonic distension of the intestine and chronic 
inflammation of the mucosa. 

For a stronger reason, we may ascribe to such chronic 
inflammations, the cicatricial results of old lesions of 
the intestines, bands, puckerings, and in particular, a 
certain rigidity of the ileo-ctecal valve deformed by 
adhesions which Bamberger has pointed out as an 
important predisposing cause, and of which Gambet- 
ta's case furnishes a remarkable example. 1 

All these causes act in the same way by hindering 
the mechanism of the contractions of the large intes- 
tine, and by determining the formation of depressions 
and hernise of the coats and the accumulation there 
of debris of faecal matters the origin of the scybala. 



1 Bamberger, Handb. der Spec. Path, und Ther. Erlangen 1864. 
See also the account of Gambetta's disease in Gaz. hebdom., Jan. 19th, 
1883. 



68 — 



We must assign a place apart to tuberculosis 
among the causes of appendicitis; but the tubercu- 
lous form is a special specific appendicitis, absolutely- 
different in its lesions, as in its evolution, from ordi- 
nary appendicitis. Tuberculous appendicitis is only 
a particular case of tuberculosis of the intestine. We 
know how frequent are bacillary ulcerations of the 
large intestine; the caecum, is one of their places of 
election. The csecal ulcerations may spread to the 
mucosa of the appendix, or they may originate there. 
If the ulcer extends deeply, it determines a chronic 
inflammation around the ulcerated organ, and some- 
times even a veritable tuberculous peritonitis localized 
and suppurative. The affection well merits the name 
of tuberculous typhlitis, for the caecum is the starting 
point and the principal seat of the alterations. But 
the appendix may be attacked predominantly, and in 
some cases (probably very rare), the consequences are 
the same as those of acute perforating appendicitis. 
Dufour has reported an instance of tuberculous per- 
foration of the appendix which was followed by gen- 
eral peritonitis, rapidly fatal. But, as a rule, tuber- 
culous typhlo-appendicitis constitutes a clinical species 
apart, distinct from ordinary appendicitis, and which 
we shall have to concern ourselves about only when 
it is a question of diagnosis. 

3. Convalescence from acute diseases. — Appendicitis 
sometimes comes on in ordinary convalescence from 
acute diseases; it has been noted as a sequel of typhoid 



— 69 — 

fever. I have seen it in an aged woman in a conval- 
escence from pneumonia. I do not believe in the 
direct influence of acute disease on the development 
of appendicitis, but in a simple predisposing action. 
A traumatism, a fracture, a wound, may have the 
same consequences in condemning the injured per- 
son to rest and to prolonged immobility, contrary to 
his habits. 

In these conditions the atony of the large intes- 
tines is the rule, and the derangement of the 
functions of the intestines provokes digestive 
troubles, or compels resort to repeated purgatives 
which are the true cause of the appendicitis. Per- 
haps also the relaxation of the walls of the appendix 
favors, in a certain measure, the penetration of fgecal 
concretions. 

4. Relapses. — The existence of a previous attack of 
appendicitis is one of the most conspicuous predis- 
posing causes. One cannot but think either that the 
foreign body remains imprisoned in the appendix, 
constituting by its presence an inflammatory thorn 
always ready to provoke new accidents ; or, that, 
although the scybalous concretion may have been dis- 
placed, the lesions determined by the first attack 
persist in a sub-acute state, being awakened from 
time to time under the action of one of the deter- 
mining causes of which we are about to speak ; or 
lastly, that the passage of the foreign body leaves 
the canal dilated and enlarged, and that this 



— 70 — 

enlargement facilitates the entrance of new con- 
cretions. 

5. Age. — The frequency of appendicitis in early 
life is so great that we are warranted in making of 
age one of the predisposing causes of the affection. 
All statistics agree on this point. 

The oldest statistics, Bamberger's, pertain to 73 
cases, with the following figures: 

Below 2 years , 2 cases. 

From 15 to 20 years 20 

" 20to30 " 32 

" 30 to 40 " 9 

"■ 40 to 50 " 5 

Above 50 years 5 

Paulier, in 49 cases, found 31 from 10 to 30 years ; 
Maurin, in 69, reckons 54 cases between 10 and 25 
years. 

The most extensive statistics are those of Reginald 
Fitz. In 228 cases of appendicitis, he gives the 
following proportions : 



20 months 
10 " 


to 10 years. 
" 20 " . 


..22 cases. 
..86 " . 


. . 10 per cent 

..38 " '• 


20 years 
30 " 
40 " 


" 30 " . 
" 40 " . 
" 50 " . 


..65 " . 
..34 " . 

..8 '« . 


..28 " " 
.,15 " " 
.. 3 " " 


50 " 


" 60 " . 


.11 " . 


.. 5 " " 


60 " 


" 70 " . 


.. 1 " 




70 " 


" 80 " . 


.. 1 " 





It will be seen that the statistics of Fitz give 
almost the same proportion of cases of appendicitis 



— 71 — 

occurring below 30 years, as those of Bamberger, 76 
per cent, instead of 72 per cent. Between 30 and 40 
years the figure falls to 15 per cent. Beyond 40 the 
affection may be considered as rare. The maximum 
frequency appears to be between the ages of 10 and 
20 years, i. e., during adolescence. 

In infancy, appendicitis is rare. This statement 
is true for early infancy, but not for early childhood. 
The statistics of Fitz indicate a proportion of 10 per 
cent, for young children. As a result of the 
observation of 72 cases of appendicitis in children, 
Matterstock gives the following figures. 

From 2 to 5 years 10 cases. 

5 to 10 " 25 " 

" 10 to 15 " 35 " 

Under 2 years 2 " 

Why is appendicitis so disproportionately frequent 
in adolescence and in the adult ? It is difficult to 
give a precise answer to this question. We may 
suppose that young people are more accustomed to 
imprudencies in diet, to violent fatigues, to drillings, 
and all conditions whose occasional role of causation 
is indicated in the observations. 

6. Sex. — There is general agreement as to the 
frequency of appendicitis in the male sex. 

Bamberger in 75 cases finds 54 men. 19 women. 

Volz in 56 " " 37 " 9 " 

Marchal, deCalviin36 " " 32 " 4 " 

Paulier in 49 " " 36 " 15 " 

Maurin in 94 " " 78 " 16 " 



— 72 — 

In adding these various statistics we find the 
proportion of 79 per cent, for men and 21 per cent, 
for women. 

The elaborate statistics of Reginald Fitz give 
exactly the same proportion. Out of 247 cases of 
appendicitis there were 197 males, i. e., 80 per cent., 
and 50 females, i. e., 20 per cent. The statistics of 
Pravaz, of Lyons, give the proportion of 25 per cent, 
of females and 75 per cent, of males. 

We may then conclude that appendicitis is more 
frequent in the male than in the female in the pro* 
portion of 4 to 1. As for the cause of this predilec- 
tion for the male sex, we can but repeat what we 
have said with reference to age. But here also the 
fact does not bear any relation to the role attributed 
by tradition to habits of constipation. 

7. Local anatomical conditions. — It has been 
supposed that the disposition of the caecum and its 
appendix was a predisposing cause. It has been said 
that the caecum plays a special role in intestinal 
digestion ; that its cul-de-sac form is an obstacle to the 
progression of faecal matters and favors their stag- 
nation ; a certain importance has also been attributed 
to the length of the appendix, and to the presence or 
absence of the valve of Gehrlach. These are pure 
hypotheses. The caecum has no digestive functions ; 
and it is not proved that faecal matters accumulate 
there in the normal state, for it is almost always 
found empty in the cadaver. As for the dimensions 



— 73 — 

of the appendix, autopsies have not proved that the 
perforated appendices have an exaggerated length. 
It is possible that the absence of the ileo-csecal valve 
favors the penetration of scybala; but as it equally 
favors their expulsion, we cannot make much account 
of this hypothesis. 

To sum up, as predisposing conditions, the two 
facts which stand out the most clearly from the 
study of the observations, are the influence of age 
and of sex. But these conditions act chiefly by 
favoring the action of the occasional causes. As for 
the formation of scybala, this seems to be especially 
in relation with functional troubles of the large 
intestine, which troubles are the resultant of old 
lesions, or of a state of sub-acute irritation of the 
mucosa. But if in these cases it is possible to refer 
the appendicitis to a chronic alteration of the intes- 
tine, we cannot overlook the fact that in a great 
number of subjects it appears as a simple accidental 
lesion independent of every other disease, impossible, 
hence, to foresee or to prevent. 

15. Occasional Causes. 

We understand by occasional causes all the causes 
which determine the penetration of a foreign body in 
the appendix. These causes all act apparently by 
the same mechanism, in provoking an irregular con- 
traction, more or less sudden, of the muscular coat 
of the caecum, a contraction which has for effect to 
keep open or enlarge the orifice of the appendix, at 



— 74 — 

the same time that it engages the faecal concretion 
there. 

a. Indigestion. — Indigestion, or at least the inges- 
tion of indigestible aliments, is so often mentioned 
as the starting point of the accidents, that it is 
impossible not to regard this circumstance as a 
frequent determining cause. This is so true that 
many cases of appendicitis are first diagnosticated 
even in the fatal forms as simple indigestion. 

I do not mean that the vomitings of the onset are 
the consequence of an indigestion. I am convinced 
that they are almost always due to a reflex abdom- 
inal irritation starting from the appendix. But the 
passage into the intestine of aliments taken in 
excess, badly digested or badly tolerated, such as 
cabbage, mushrooms, carrots, turnips, game too high, 
etc., provokes abnormal movements of the digestive 
canal which determine the engagement of the 
stercoral calculus in the appendix. 

Purgatives act in the same way, probably, in 
cases where the onset of the affection is attributed to 
them. 

b. Exposure to cold and getting chilled. — This com- 
mon cause of almost all diseases has also been 
mentioned among the causes of appendicitis. The 
occasional role of chilling does not seem to be dis- 
puted. It is of common observation that a sudden 
exposure to cold, or even getting the feet cold, will 
cause attacks of abdominal colic in certain predis- 
posed persons. On the other hand, the experiments 



of Rossbach on a woman whose abdominal walls 
presented such a thinness that one could easily detect 
through the skin the movements of the intestine, 
prove that a slight degree of cold, such as the simple 
exposure of the abdomen to the air, produces a lively- 
movement of peristalsis at the end of a few minutes, 
or augments the force of the contractions if they 
already exist. It is, then, right to include chilling 
among the causes which, in stimulating the intestinal 
contractions, favor the displacement and engagement 
of the faecal bolus in the appendix. 

c. Travmatzsm. — Traumatism is an occasional 
cause quite frequently mentioned. The statistics of 
Fitz give this cause in 10 per cent, of the cases. We 
must understand by traumatism not only a blow on 
the abdomen, a fall, but also every violent effort, 
such as lifting a weight, dancing, leaping, gymnastic 
exercise, forced marching. It is not rare to see this 
cause associated with digestive troubles. Thus we 
find in a certain number of cases the onset of the 
appendicitis coincident with a fatigue, or violent 
exercise, during the first hours of digestion. 

These divers causes being recorded, it must be 
added that it is by no means possible always to find 
them in interrogating the patients. In perhaps half 
the cases the etiology remains nil. In particular, in 
that fulminant form which we call hyper-acute per- 
forating appendicitis, the appendicitis manifests itself 
suddenly in a robust and healthy subject, without 
anything to explain the explosion of the accidents. 



IV. 

THE SYMPTOMS. 

The ordinary clinical type of appendicitis is quite 
as simple as that of acute fibrinous pneumonia. A 
young man, or an adult still young, of habitually 
good health, or suffering for some time from vague 
digestive troubles, is suddenly taken with a severe 
pain in the right iliac fossa. This pain is accom- 
panied with colicky paroxysms more or less violent, 
followed or not by one or two attacks of vomiting 
of food or bile. Then the colics subside, but the 
fixed pain continues, sometimes exactly limited to a 
point of the iliac fossa, sometimes more diffuse. The 
muscles of the region are hard and tense, preventing 
all deep exploration ; the fever is in general of little 
intensity. 

The symptoms may be limited to this, and at the 
end of seven or eight days the tension and the iliac 
pain diminish gradually. But in other cases, to the 
first attack of pain succeeds more or less rapidly, 
sometimes at the end of 24 to 48 hours, sometimes 
still later, a new crisis of generalized abdominal 
pains with incessant vomiting of bilious or porraceous 
matters ; the belly becomes hard, tense and sensitive 
throughout its whole extent with predominance of 
the morbid signs on the right side; the face becomes 
pinched, the extremities cold, and the patient suc- 
cumbs with all the symptoms of diffuse peritonitis. 



- 11 — 

At other times the pain, which at first spread over 
the whole abdomen, concentrates itself in the right 
iliac fossa, and at the end of several days the medical 
attendant notices that in this region a more or less 
extensive doughy swelling has replaced the first 
rigidity of the muscles on that side. The fever, 
which was before but little marked, rises and 
becomes remittent, with evening exacerbations ; the 
constipation may persist, but the stools are often 
diarrhceic. At the end of 12 days or so, there can 
no longer be any doubt that there exists in the right 
side of the abdomen a purulent collection. 

The subsequent course of the affection depends on 
the treatment employed, and necessarily varies 
according as surgical interference is resorted to or 
not. 

Such are, in their broad lineaments, the three 
principal forms of acute appendicitis, according as 
the affection pursues a rapid course, either towards 
resolution, or towards perforation with diffused 
peritonitis or with localized peritonitis. 

We call the first form simple parietal appendicitis 
with appendicular colic ; the second, liyper-acute per- 
forative appendicitis ; the third, acute appendicitis 
with partial peritonitis. 

But these three forms do not exhaust all the 
modalities of the disease. There still exist cases 
where the appendicitis begins in a sudden and acute 
manner, and the accidents then take on an insidious, 



78 — 



slow and irregular course, with febrile attacks and 
apyretic intervals — periods of pain and periods of 
calm — with alternations of amelioration and 
aggravation, which may continue for weeks and for 
months. There are other cases where, after the 
onset has been vague and insidious, the symptoms 
having been characterized for some days by pain- 
lessness and semi-latency, all at once the disease 
takes on an acute character. In these cases either 
the perforation has already taken place into the 
peritoneum, though tardily and after numerous 
adhesions have had the time to be organized all 
around the appendix ; or else the appendix, 
embedded in the retro-caecal cellular tissue, and 
without immediate relation with the serosa, has 
ruptured into the connective tissue, and the rupture 
has caused a phlegmon of the ilio-lumbar region. I 
shall group these forms under the name of sub- 
acute perforative appendicitis. 

Lastly, there exists a fifth clinical variety which, 
by its special evolution and by the operative problem 
w T hich it raises, merits a description apart. I refer 
to recurrent appendicitis. This variety should be 
differentiated from the simple relapses which 
appendicitis sometimes presents. The recurrences 
habitually take on the clinical aspect of simple 
appendicitis with appendicular colic ; the patient is 
none the less in danger of seeing at times the affec- 
tion take on the character of one of the three other 
forms which we have briefly sketched. 



— 70 — 

16. Hyper- Acute Perforative Appendicitis. 

We shall describe, in the first place, this hyper-acute 
form, because it represents the clinical type, which 
is the most clear, the best defined, and the most 
easily recognized. 

The perforation may take place at all periods of 
the appendicitis, just as it is a permanent menace in 
all the periods of simple ulcer of the stomach. But 
just as there exists a special form of round ulcer of 
the stomach called perf orating ulcer of young women, 
of which the perforation is, so to speak, the first and 
the only symptom, so there exists a form of 
appendicitis which by its characters, its fulminant 
course and its rapidly fatal termination, deserves to 
be specialized under the name of hyper-acute perf or- 
ative appendicitis. 

This is the form that we proposed in 1882 to 
distinguish from the other forms of typhlitis by 
the name of acute perforative typhlitis. We 
indicated at that time the mechanism of the perfora- 
tion by the direct action of microbes, and the indirect 
action of the coprolith playing the part of an 
obstructing plug. 

Although the mechanism of the perforation is, we 
believe, the same in the other forms of perforative 
appendicitis, here the consequences of the obstruction 
of the canal, and the compression exercised on its 
walls, are brought to their maximum of intensity, 



— 80 — 

In order that this form may be observed it is 
necessary : 

1. That the strangulation produced at the base of 
the appendix by the foreign body introduced into 
its cavity shall be as complete as possible; 

2. That the appendix shall be free in the 
peritoneal cavity. 

The first condition determines the immediate 
gangrene of the walls of the appendix which become 
rapidly perforated in one or more points ; the second 
has for its consequence the instantaneous diffusion of 
the inflammation to the entire extent of the serosa. 

Hence this form is seen chiefly in healthy persons 
without any hereditary predisposition to appendi- 
citis, as far as can be known. It has been said 
that the perforation is not ordinarily produced 
during the first attack ; this is true in a certain 
measure for the other varieties of perforative 
appendicitis, but it is not true for the hyper-acute 
form. Recurrent appendicitis may, it is true, in 
some cases, give rise to a general peritonitis, but the 
first attacks will always have been wide apart, but 
little marked, and of no more consequence than any 
simple appendicular colic ; in general, it determines 
only a localized perityphlitis. 

The symptoms and the evolution of hyper-acute 
appendicitis present a remarkable uniformity. All 
the observations of this kind are similar, and seem, 
so to speak, modeled the one on the other. 



— 81 — 

There are two distinct periods : the preparatory 
period which precedes the perforation, and which 
we have proposed to call the period of appendicular 
colic, and the peritoneal phase, which follows the 
rupture of the appendix. 

1. Period of Appendicular Colic. — This first 
period may be very short, and not exceed 24 
hours ; ordinarily it is prolonged from two to three 
days. After one of the occasional causes indicated 
above, an indigestible or too copious meal, for 
instance, the patient is taken, sometimes, with a 
violent attack of abdominal pains, rapidly followed 
by one or more vomitings of food or of bile, at 
other times with dull heavy pains, which are more 
easily borne. These pains have sometimes their 
maximum of intensity on the right, and seem to 
radiate from the iliac fossa on that side ; but very 
often they are diffuse, peri-umbilical, and do not 
differ from an ordinary colic. 

When they are very intense, there is from the first 
obstinate constipation ; when they are dull, the 
patient may have one or two natural stools. 

Whether they have begun severely or mildly, 
these colics persist for two or three days ; there may 
even then be a lull of from 12 to 24 hours, during 
which the patient thinks himself cured. 

The fever at this moment does not exist, or at 
least it is but little marked ; there is only gastric 
embarrassment, with dirty tongue, bad taste in the 

6 



— 82 — 

mouth, want of appetite. This period corresponds 
to the engagement of the stercoral calculus in the 
appendix, and to the work of destruction of the 
microbes in its walls. 

2. Peritoneal period. — Suddenly, the second or 
third day, the scene changes ; the abdominal pain 
reappears with extreme intensity, and this time it is 
certainly most marked in the right iliac fossa ; 
rapidly it diffuses itself all over the abdomen and 
becomes intolerable. 

This new attack of pain indicates that the perfor- 
ation has taken place into the peritoneum, and 
thenceforth the symptoms are those of peritonitis by 
perforation. The pain, although general, is 
especially felt in the right side of the abdomen ; it is 
continuous, with moments of exacerbation ; the least 
movement, the least contact immediately exasperates 
it. The pressure of the hand increases it every- 
where, but especially in the loin and in the right 
iliac fossa ; the difference is sometimes so well 
marked that the physician is led to doubt of the ex- 
tension of the peritonitis to the left. 

The abdomen is not generally tympanitic, it is, 
on the contrary, flat ; sometimes almost excavated, 
but extraordinarily hard and tense, especially on the 
right side ; a certain degree of meteorism may 
develop if the disease is prolonged. The rigid con- 
traction of the abdominal muscles no longer permits 
exploration or serious palpation. Percussion itself 



— 83 — 

is very painful ; it shows moreover a sonorousness 
almost normal, and does not furnish any useful 
information except in certain cases when, towards 
the end, shortly before death, there is noticed a 
slight decree of dullness on the right, due to the 
predominance of the membranous exudation at that 
point. 

The vomitings, which had ceased with the first 
attack of colic, reappear at the moment of perfora- 
tion with the characters of peritoneal vomiting. 
They are at first incessant, repeated ; the patient 
rejects everything that he swallows, foods, drinks, 
medicines; the vomitus soon becomes porraceous 
and greenish, often frecaloid, under the form of a 
yellowish pea-soup liquid. 

To the vomiting is added an obstinate constipation. 
Neither purgatives nor lavements bring away any- 
thing, not even gas. This absolute suppression of 
the intestinal functions, due to reflex paralysis of the 
large intestine, taken in connection with the fascal 
vomiting, might lead one to suspect internal 
strangulation, and many a mistake of this kind has 
actually been committed. In this regard peritonitis 
by perforation of the appendix does not differ from 
other kinds of peritonitis by perforation, whether 
the seat of the perforation be the stomach, the 
duodenum, the gall bladder, etc. 

The bladder and even the kidney undergo the 
same effects of inhibition as the large intestine. 



— 84 — 

There is not only retention of urine, but even 
oliguria, and sometimes anuria. Not only does 
catheterism become necessary in order to empty the 
bladder, but only a small quantity of urine can be 
obtained by the catheter. This urine is high-colored 
and dense ; if treated by Gubler's test, the nitric acid 
gives a disk of albumen of greater or less thickness, 
and below that a bluish or indican-violet disk. There 
may be little or no albumen, but in treating the urine 
by hydrochloric acid and chloroform, one will always 
find indican in abundance. 

These disturbances of the urinary secretion are the 
ordinary consequences of the peritoneal shock ; they 
are probably of neuro-vascular origin. We may 
make three suppositions : 

1. The albuminuria is due to the elimination of 
toxic intestinal products reabsorbed by the blood, 
and then excreted by the renal filter, where they 
irritate the glomerular epithelium. This is the 
hypothesis proposed by English to explain the 
albuminuria of hernial strangulation. 

2. It is due to the elimination of microbes pro- 
liferating in the peritoneum, and easily passing from 
the peritoneum into the blood, to be then eliminated 
by the kidney. 

3. It is due to the retardation of the glomerular 
circulation, a consequence of the general fall in the 
arterial tension. 

The two first suppositions are not demonstrated; 



— 85 — 

the probability of the third is attested, on the one 
part, by the oliguria which always accompanies 
the albuminuria, and on the other by the feeble- 
ness of the cardiac pulsation and the smallness of the 
pulse, which are always observed in such cases. 

The violence of the abdominal shock explains, 
moreover, the characters of the thermic curve. The 
temperature is never very high ; it rarely exceeds 
39° C, and ordinarily stands between 38° and 39°; 
sometimes it even falls below the normal, and the 
central coincides with the peripheral depression of 
temperature. 

The facies of the patient is characteristic ; it is 
the facies abdominalis or Hippocraticus : the visage 
is excavated, contracted ; the eyes sunken, with 
black circles ; the nose pinched ; the extremities are 
violaceous and cold ; the voice feeble and broken. 
The beatings of the heart are precipitate and feeble, 
though .regular ; the pulse is small, without force, 
fivquent, and becomes more and more shabby. The 
patient lies prostrate on his back, with thighs semi- 
flexed ; moves with pain, the least movement 
aggravating his abdominal sufferings ; his groans are 
continuous ; the respiration is short, dyspneeic. 
Often an incessant hiccough adds to his torments ; 
there is burning thirst, the mouth is dry, the tongue 
covered with a dirty or fiery red^coat. 

Death ordinarily ensues on the eighth or ninth 
day. In 1 76 cases collected by Fitz, death super- 



— 86 — 

vened in the first week in 98, and in the second week 
in 54 ; in only 24 did the patient survive more than a 
fortnight. 1 

In certain cases a fatal termination is very rapid ; 
it may take place the second, third or fourth day, 
according to the statistics of our American authority. 
But it is not altogether clear whether this writer 
reckons from the onset of the sickness or from the 
moment of the perforation. 2 

What is certain is, that with the same apparent 
lesions, there are cases where the peritonitis is, so to 
speak, fulminant, and others where the course is 
more slow. It is probable that cases of the first kind 
are in relation with an exudation which is highly 
septic ; those of the second class, with a peritonitis 
predominantly purulent. The first kill rather by 
blood-poisoning ; the second by exhaustion. It is 
to be hoped that the bacteriological study of the 
exudation will some day give the key to these 
differences. While waiting for such help, we believe 



1 These are Fitz's statistics for the first week : 

Death on the second day 8 cases. 

" " third " 20 " 

" " fourth " 12 " 

" " fifth " 20 " 

" " sixth " 16 " 

" " " seventh " 22 " 

Besides, 54 died on the first week, 8 in the third, 7 in the fourth, 4 in 
the fifth, 4 in the seventh, one in the eighth : but these cases must 
surely have been cases of partial suppurative peritonitis. 

2 Certainly from the onset of the attack. Tr. 



— 87 — 

thai the following clinical features will enable one 
to distinguish these two varieties of diffuse peri- 
tonitis. 

Septic peritonitis is characterized by the violence 
and rapid progress of the accidents. It is this type 
which we have had chiefly in view in our description. 
It is to it that belong the abdominal collapsus, the 
extreme prostration, with general coldness, the fall of 
the central temperature, the scanty vomiting, the 
general rigidity of the muscles of the abdomen, char- 
acterized rather by hardness and flatness than by 
meteorism with barrel-shaped belly, the extreme 
oliguria with albuminuria and indican in the urine; 
lastly, the rapid death in several days. The patients 
succumb two, three or four days after the perfora- 
tion; it is rare that they survive to the end of the 
first week. 

In the peritonitis which is predominantly purulent, 
the evolution is less boisterous and less continuous. 
There are from time to time more acute attacks of 
pain, of fever and of vomiting. There is the 
abdominal cast of countenance, but the facies is less 
pinched, less depressed. The general depression of 
temperature is lacking. The central temperature is 
higher and may by moments attain to 40° C. The 
belly is not hard and tense, but more or less tympan- 
itic. The vomitings are more frequent and the con- 
stipation less absolute. The urine is scanty and high- 
colored, but may be free from indican and albumen. 



— 88 — 

Lastly, the disease may be prolonged 12 or 15 days 
and even more, while being not less surely fatal than 
the septic form, unless the surgeon saves the patient 
by a laparotomy. 

17. Simple Parietal Appendicitis with Appen- 
dicular Colic. 

Hyper-acute appendicitis represents the type of 
the affection at its maximum of gravity ; at the 
other eud of the series is placed simple appendicitis 
with the minimum of intensity. The causes, the 
mechanism, the mode of the onset, are the same ; 
but the perforation does not take place: everything 
is limited to simple inflammation, catarrhal or 
parietal, of the appendix, and in a few days the 
symptoms abate and disappear. The peritoneal 
phase is then wanting, the lesions are limited to the 
appendix, although in certain cases the violence of 
the sympathetic phenomena may go so far as to 
resemble peritonitis and produce that symptomatic 
aggregate which Gubler designates by the name of 
peritonism. 

This simple appendicitis corresponds to the 
affection which the old writers described under the 
name of stercoral typhlitis and of simple typhlitis. 

We have shown (see paragraph 6) that all the 
symptoms attributed to typhlitis are easily explained 
by the irritation of the appendix ; the sudden onset 
by the engagement of the stercoral calculus in the 



— 89 — 

appendicular canal, the radiating and paroxysmal 
pains, under the form of colics, by the reflex 
excitation of the intestine, starting in the mucosa of 
the duct in contact with the foreign body, the 
vomitings due to the same excitation, propagated to 
the stomach, the constipation and meteorism by 
paresis of the muscular coat of the intestine, accord- 
ing to the mechanism common to all violent pains of 
the abdominal region, whether this pain has its 
starting point in the stomach, the ureter or the bile 
ducts. 

As for the tumor, described as an elongated, 
cylindrical mass, dull to percussion, and moulded to 
the form of the caecum, it does not exist in the large 
majority of cases. In the first days of the attack 
what is noticed is a contracture of the abdominal 
muscles on the right side, a contracture similar to that 
which is observed over the region of the liver or 
stomach when these organs are the seat of a severe 
pain. This muscular rigidity prevents at the onset 
all deep exploration. When it yields with 
subsidence of the pain, it is possible in some cases 
to find a tumefaction more or less elongated, 
resembling the form of the caecum, and due to the 
stasis of faecal matters. This stasis is, in that case, 
simply the consequence of paresis of the large 
intestine, just as is the constipation and the 
tympanites ; it is not the cause of the accidents. 
But this stercoral tumor is rarely met, being often 



— 90 — 

merely an illusion, created and maintained by a pre- 
conceived notion ; and in all cases it is always 
observed posterior to the explosion of the accidents. 

It seems to us useless to take up one by one the 
symptoms of simple appendicitis. It is preferable 
o establish several clinical varieties, according to 
tthe intensity of the crisis and the rapidity of its 
evolution. We shall admit three principal varieties: 
Appendicular colic, a medium type, appendicitis 
with peritonism or pseudo-peritonitis. 

1. Appendicular Colic. — This is the simplest 
aspect under which the accidents can present them- 
selves. The symptoms may be of extreme violence, 
but they are always of short duration, and every- 
thing is restored to the normal order at the end of 
12, 24 or 36 hours, either spontaneously or in con- 
sequence of a subcutaneous injection of morphine or 
some other calmative means. This variety markedly 
resembles an attack of hepatic or renal colic. 
According to its intensity, it may and m ust often be 
confounded with one of these calculous crises,, 
whether accompanied with an indigestion or a simple 
intestinal colic. 

In fact, it is really a case of intestinal colic, 
attended with vomiting ; it is specialized by the 
origin of the pain, which is the appendix, and this 
starting point may be clinically determined by the 
existence of a fixed painful point of extreme 
sensibility. This point corresponds to the base of 



— 01 — 

the appendix ; it is seated exactly in the right iliac 
fossa, on a line drawn from the umbilicus to the 
antero-superior spine of the ilium, about four fingers' 
breadth inside of the spine. This is what is called 
MacBurney^s point. * 

If the crisis never returns, there will always remain 
a doubt concerning the diagnosis. But the reality of 
this appendicular colic is attested by the following 
facts : 

1. One often witnesses similar crises in the ante- 
cedents of subjects who eventually have an attack 
which presents the indisputable signs of acute 
appendicitis, perforative or non-perforative. 

2. It is one of the habitual episodes of so-called 
recurrent appendicitis. M. Charles Leroux has 
published a case of this kind remarkable for the 
clearness, the violence and the frequency of the 
crises, in the Revue des maladies de VenfancL 1 

3. Lastly, the early operations of American sur- 
geons, made in consequence of one of these recurrent 
attacks, have shown that often the appendix presents 
no lesion caj>able of explaining the observed 
symptoms. Dr. Bull has reported, among others, 
two cases of this kind. In one case the patient was 
a physician; the excised appendix appeared normal; 
it contained no faecal concretion, and there existed in 
the vicinity no trace of old or recent peritonitis or 



] Ch. Leroux. Revue des maladies de Venfance, January, 1891. 



— 92 — 

of adhesions. In the other case the appendix was 
found simply bent on itself ; it enclosed neither 
liquid nor scybala, it was merely somewhat 
thickened ; but surely this slight thickening of the 
walls could not account for the painful crises. 1 

In these conditions it is necessary to admit a cause 
of irritation so transient as to leave no serious trace 
of its passage. And what hypothesis more probable 
than that of a stercoral calculus penetrating suddenly 
into the muscular canal of the appendix, provoking 
the spasmodic contraction and all the painful con- 
sequences which proceed from such a contraction, 
then falling back into the caecum, and, in becoming 
disengaged, bringing on the cessation of the crisis ? 

What characterizes this first clinical form is its 
sudden termination without other accident. The 
painful crisis having subsided, all is over. On the 
next day pressure over Mac Burney's point will 
scarcely awaken any sensibility; but there is neither 
muscular rigidity nor deep swelling, nor anything 
which indicates any inflammatory process whatever. 
All is then limited, as in hepatic or renal colic, to a 
nervous crisis, to the painful and reflex phenomena 
provoked by the excitation of the duct. 

2. Ordinary Mean Type. — But, as we have said, 
the fsecal concretion may remain engaged in the 
appendix, impeding the parietal circulation suf- 



Bull. New York Med. Record, April 26th, 1890. 



93 



ficiently to facilitate the inflammation of the walls,. 
not enough, however, to determine their gangrene, 
whether because the foreign body is less voluminous, 
or because the walls are more extensible. In these 
conditions, the initial attack of colic is followed by a 
localization of the pains in the right iliac fossa, 
with elevation of the temperature more or less 
marked, in relation with the parietal inflammation 
of the appendix. 

We shall give an idea of this form by reproducing 
the following observation, which sums up its exact 
symptoms: 

A man aged 35 years, of habitually good health, is 
suddenly taken one day while breakfasting with a 
violent abdominal pain, which he compares to a 
colic. This pain, which at first extended all over 
the belly, soon becomes localized in the right iliac 
fossa. In the evening he has a stool and several 
bilious vomitings. 

The following day he awakes with fever, general 
malaise, anorexia; there are three or four vomiting 
spells; pain always very severe; there is also 
constipation. These symptoms persist the following 
days, except the vomiting, which does not reappear. 

The sixth day the following condition is observed: 
The patient complains of violent pains in the right 
iliac fossa; he localizes this pain exactly four fingers' 
breadth outside of the median line, a little below 
the antero-superior spine of the ilium. Pressure 



_ 04 — 

made on this point with the finger provokes a very 
severe pain. The belly is not tympanitic; bat the 
abdominal wall offers great resistance to palpation 
over the region of pain. The temperature is 38° C; 
the evening of the preceding day it was 38.4°. 
Fifteen leeches loco dolenti are prescribed, and 
castor oil is given in teaspoonful doses every half 
hour. The subsequent history is as follows: 

After taking the purgative, the patient had seven 
or eight greenish stools, very fetid, composed of 
solid matter and of mucus, which he compared to 
white of egg. The iliac pain was less ; the abdom- 
inal wall was still resistant; no tumor was perceived 
by palpation. The fever was gone; M. T, 31° C. 

The eighth and ninth days the condition was the 
same; constipation, which necessitated another 
purgative of oil; abundant stools. The iliac region 
was continually painful. No fever. 

The tenth day the abdomen could be freely 
manipulated, and by palpation there was noticed a 
small elongated tumor of the size of the thumb, 
painful to pressure, situated a little inside and below 
the antero-superior spine of the ilium. 

The following days the patient continued to com- 
plain of the iliac pain, especially when he arose. He 
left the hospital the nineteenth day in spite of our 
protestation. The small tumor, painful to pressure, 
persisted in the iliac fossa. 

We see, in summing up, that we had here an 



— 05 — 

affection of little gravity, pursuing its course quite 
rapidly in from eight to fifteen days, and of which 
the symptoms reproduce exactly the clinical picture 
formerly ascribed to simple and stercoral typhlitis. 
There are two kinds of pain: one fixed, iliac, 
limited, and quite clearly circumscribed, correspond- 
ing to the inflamed appendix (Mac Bnrney's point), 
complained of by the patient and provoked by 
pressure; the other, paroxysmal, diffused all over the 
abdomen, which does not differ from the ordinary 
pain of intestinal colic, and which is moreover due 
to the same cause: the reflex contractions of the 
large intestine. 

The fever is not pronounced; but the constipation 
is habitual. 

To the fixed pain there corresponds a sense of 
resistance, a rigidity of the abdominal muscles of the 
right side, which in the first days prevents deep 
palpation. 

When this painful contraction yields, there is then 
noticed, in depressing the wall of the iliac fossa, a 
small elongated tumor, sensitive to touch, of the size 
of the finger, which is simply the inflamed and dis- 
tended appendix. 

In the simplest cases this tumefaction undergoes 
resolution and gradually disappears; in others, on 
the occasion of a movement, a strain, an indiscretion 
in diet, to the first attack there succeeds another 
which yields quite as rapidly as the first, but which 



— 90 — 

may take on a course more acute, with peritoneal 
complications. Sometimes, in the same sickness, 
three or four exacerbations of this kind succeed each 
other at short intervals with violent paroxysmal 
pains. It might be supposed that in these cases 
there is a simple displacement of the scybalum in the 
appendix. When one of these attacks is prolonged, 
one may well fear, however, the extension of the 
inflammation to the neighboring peritoneum. 

Patients that have had an attack of appen- 
dicitis, ordinarily remain affected with constipation 
and an atony of the large intestine difficult to over- 
come. Sometimes the atonic dilatation of the large 
intestine predominates in the caecum, which then 
forms a veritable gaseous tumor in the iliac fossa. 
They are, besides, exposed to further attacks at 
greater or less intervals, and the initial crisis is often 
only an episode of recurrent appendicitis. 

3. Appendicitis with peritonism or pseudo-peri- 
tonitis. — In cases where there is, anatomically 
speaking, nothing but a simple inflammation of the 
appendix, the symptoms of nervous irritation may in 
exceptional cases be sufficiently intense to induce 
belief in a peritonitis, diffused or localized. 

The pseudo-peritonitis of hysterical women is well 
known. Under the influence of an intense general 
excitation, of a menstrual trouble, or perhaps of a 
slight lesion of the tubes, suddenly all the symptoms 
of an acute peritonitis are seen to supervene: ex- 



— 97 — 

cruciating abdominal pains, extreme hyperesthesia 
of the belly, porraceous vomitings, pinched facies, chil- 
ling of the extremities, frequency and smallness of the 
pulse, sometimes even slight thermic elevation, with- 
out the existence, however, of anything but a pain- 
ful contraction of the abdominal muscles. The same 
phenomena may be observed in the hysterical man; 
we have just seen a remarkable instance as the sequel 
of an abdominal traumatism. It is easy to under- 
stand, then, that in nervous subjects, and for a 
stronger reason in the hysterical, a severe pain 
radiating from the appendix may provoke similar 
consequences, which may resemble, now a general 
inflammation of the serosa, now a partial peritonitis 
of the right iliac fossa, with localized tumor. 

We see hardly any other explanation than local- 
ized peritonism to give of the observation reported 
by Dr. Shrady of New York. It concerned a physi- 
cian affected with recurrent appendicitis. Three of 
these attacks were observed by Dr. Shrady; the fourth 
took place in Paris, where the patient was seen by a 
distinguished surgeon, who made the same diagnosis. 
Each of the recurrences was accompanied by symp- 
toms which warranted the fear that an abscess was in 
process of formation: dullness, sensibility to pressure, 
rigidity of the walls, slightly oedematous swelling in 
the vicinity of the caecum. At each crisis, the ques- 
tion of surgical intervention was agitated, both in 
Paris and New York. The patient affirmed that he 



— 98 — 

was ready to undergo all the risks; but each time 
the symptoms abated, and gradually disappeared. 
This physician having succumbed to an intercurrent 
malady, some time after the fourth attack, Dr. 
Shrady performed the autopsy, as he had promised to 
do, and noted that the appendix was perfectly 
healthy; it was not even thickened; neither the peri- 
cecal tissue nor the peritoneum presented the slight- 
est trace of inflammation. 

The absence of appendicular lesions in a certain 
number of cases of recurrent appendicitis operated 
upon is not absolutely rare; these facts justify our 
theory of appendicular colic. But in view of the 
local signs observed during life, how shall we inter- 
pret the absence of all peritoneal lesions ? We cannot 
admit that at each crisis there takes place an attack 
of fibrinous peritonitis of which the resolution is 
completely effected. Four acute attacks of peritoni- 
tis would surely have left some adhesions. We must 
then believe that Dr. Shrady's patient was a victim 
of nervous pseudo-peritonitis, which gave rise to a 
misleading sensation of localized tumor. 

18. Acute Appendicitis, with Localized Peri- 
tonitis. 

This form includes most of the cases described 
under the name of acute perityphlitis. We must 
distinguish two varieties, according as the appendici- 
tis is perforative or not, and according as the peri- 



— 99 — 

tonitis remains fibrinous or suppurative. It is not 
demonstrated that a non -perforative appendicitis can- 
not give rise to a purulent peritonitis or that a fibrin- 
ous peritonitis may not be observed along with a 
perforative appendicitis. But these two eventualities 
are certainly exceptional, and as practically there is 
no interest in multiplying to excess these clinical 
forms, and it will not do to base a description on ex- 
ceptions, we will only admit two varieties, acute 
appendicitis with fibrinous peritonitis, and perfora- 
tive appendicitis with circumscribed purulent peri- 
tonitis. 

a. Acute appendicitis with partial fibrinous peri- 
tonitis. — With a greater intensity, this variety repro- 
duces the symptoms of simple appendicitis; it gives 
rise besides to a painful tumefaction of the right 
region of the abdomen, a tumefaction which progres- 
sively undergoes resolution, and which is not ob- 
served when the appendix alone is the seat of lesion. 
Here the inflammation spreads rapidly by continuity 
of tissue to a certain extent of the neighboring peri- 
toneum. This peritonitis is the analogue of the 
pleurisy which accompanies cortical pneumonia, and 
of the local pelvic peritonites which supervene in 
the female around the uterine annexes. 

It remains fibrinous, then it terminates by resolu- 
tion. Although certain authorities seem to believe 
that suppurative perityphlitis may get well by 
resolution, we are inclined to doubt this. Encysted 



— 100 — 

suppurative peritonitis sometimes gets well, as we 
shall see, but on condition that the purulent collec- 
tion shall be evacuated either externally, spon- 
taneously or by the bistonry, or into some one of 
the neighboring organs, the rectum, caecum, etc. If 
resolution takes place by medical means, it is 
because there was no pus. 

This appendicitis with fibrinous peritonitis corre- 
sponds, then, to the cases described by the old 
writers as simple perityphlitis terminating in resolu- 
tion. They placed the seat of the lesion in the 
peri-csecal cellular tissue, and regarded it as a 
phlegmon stopping short of the period of suppura- 
tion. This is possible in some cases, but here also, 
as in the following form, an early laparotomy shows 
what the physical signs already had indicated, that 
the case is generally complicated with a peritoneal 
inflammation. 

The following observation, borrowed from the 
memoir of Roux, of Lausanne, 1 is one of many which 
confirm this view. It will give at the same time a 
general idea of the progress of the disease 

A boy aged 15 yea r s, affected with dyspepsia with 
habitual constipation, remained constipated from 
May 31st to June 3d; then was taken with profuse 
diarrhoea with violent pains all over the abdomen. 
In the night of June 4th-5th, about 3 a. m., severe 



1 Revue Medicate de lafiuisie romande, October, 1891, p. 581. 



— 101 — 

pains in the ileo-caecal region; continuance of 
diarrhoea; no vomiting. Despite his pain the boy- 
walked to the hospital. 

June 6th, the following condition was noted: 
Patient a good-sized boy, a little pale; tongue but 
little coated; abdomen normal with the exception of 
a little bulging at the epigastrium, as well as at the 
external limit of the right rectus abdominalis below 
the umbilicus. This slight prominence is more 
marked by the side of the right iliac spine and along 
the external half of Poupart's ligament. 

On palpation, which was painful, there was felt 
in front of the spine, at the most sensitive point, an 
ovoid resisting body adherent to the external half of 
Poupart's ligament, which extended inwardly and 
below as far as the iliac vessels, and outwardly to 
the spinoso-umbilical line, and upwards to the middle 
of this line. This tumor presented a prolongation in 
the direction of the umbilicus as large as a pigeon's 
Ggg- Nowhere was the dullness absolute; the 
colon, supple, painless, was empty. There was no 
lumbar pain; no trace of swelling of the caecum. A 
laparotomy was performed, through without any 
precise indication for the operation, as the diagnosis 
which suggested itself was simple catarrhal appen- 
dicitis without abscess and without perforation. 

The usual oblique incision under ether was made 
down to the abdominal cavity, when there issued an 
abundant quantity of lemon-yellow serous liquid. 



— 102 — 

The vermiform process was found tumefied and pro- 
jecting, resembling the penis of an infant in erection. 
It length was eight centimetres; it was very 
turgescent, resistent to pressure, and did not appear 
to contain any foreign body. It was accompanied 
by its mesentery as far as its extremity. Its point 
of insertion and its base were covered by fibrinous 
membranes which were lacking elsewhere. — Ligature 
of the mesentery; resection of the appendix at half 
a centimeter from its insertion, and walls sutured 
with catgut. The region was brushed over witji a 
sponge wrung out of a sublimate solution. 

Recovery by first intention on the 16th of June, 
when the first and only dressing was removed. 

It will be seen that the onset is the same as in the 
other forms of appendicitis already described; the 
appendicular period, characterized by diffuse 
abdominal colics, exists here as in the fulminant 
form or in simple appendicitis, preceding the local- 
ization of pains in the csecal region. The peritoneal 
vomitings ordinarily accompany this localization; 
but the preceding instance proves that they may be 
lacking. Per contra, while in simple parietal appen- 
dicitis, one will notice by palpation only a painful 
rigidity of the muscles* of the region, in appendicitis 
with peritonitis, from the first 30 hours, a tume- 
faction more or less limited is already appreciable in 
the right iliac fossa. In the case which we have 
just cited, this tumefaction was not large, and the 



— 103 — 

peritonitis was yet very limited, while the course of 
the malady was, moreover, suddenly and happily 
interrupted by surgical intervention. 

But suppose the surgeon had been less bold and 
the operation deferred or declined, the appendicular 
peritonitis would probably have extended as it does 
in other patients when left to themselves. It would 
have agglutinated the neighboring intestinal coils, 
and so formed, with the false fibrinous membranes 
and the liquid effused among the coils, a tumor more 
or less voluminous, more or less hard, resistant, 
sensitive to pressure, dull at some points, sonorous 
at others, occupying the entire iliac fossa, extending 
more or less above and within, now fixed, now 
susceptible of a certain displacement en masse. This 
tumor is in general constituted with these characters 
from the fifth to the eighth day, and is more easily 
distinguished at this moment, when the muscular 
relaxation permits a methodical exploration. 

In such a case, the peritoneal symptoms are 
naturally much more noticeable. The pain in the 
right side is intense, preventing the patient from 
moving, and is aggravated by the least contact; the 
vomitings are frequent, the nausea almost continual; 
gastric disturbance, with dry and saburral tongue, is 
sometimes very marked. The fever is very irregular; 
it may be high at the onset, exceeding 39° C, but it 
soon falls to 38° or 39° C. 

At the end of six, eight or ten days the acute peri- 



— 104 — 

toneal attack subsides; the symptoms amend, the 
tumor steadily diminishes, while the intestinal func- 
tions are reestablished. An average of 15 to 20 days 
suffices for the resorption of the peritoneal exudation; 
after which nothing is found in the iliac fossa but a 
small mass, elongated, ovoid, rolling under the 
finger, which is the appendix still surrounded with 
plastic products, and not, as was formerly taught, a 
relic of the phlegmonous induration of the sub-peri- 
toneal cellular tissue. The resorption of the fibrino- 
serous effusion may be, however, very slow, and 
sometimes there is felt, even at the end of five or six 
weeks, a hard, sensitive tumor as large as the fist, 
which gradually disappears unless, indeed, a. relapse 
takes place. 

b. Acute Appendicitis with Circumscribed Puru- 
lent Peritonitis. — The different forms of appendicitis 
which we have just indicated may be described 
under the name of medical appendicites, the inter- 
vention of the bistoury not being demanded in cases 
of this kind. Appendicitis with suppurative peri- 
tonitis represents on the contrary true surgical 
appendicitis, and can hardly be said to be curable 
without a surgical operation. 

The first phases are identical with those of the pre- 
ceding variety: a preparatory period of appendicular 
colic, followed at the end of 24 to 48 hours by signs 
of a localized peritonitis, intense iliac pain, vomit- 
ings, extensive tumefaction, steadily spreading over 
the entire right side of the belly. 



— 105 — 

In some cases, even, the symptoms of the onset do 
not differ from those of hyper-acute perforative 
appendicitis; that is to say, the phenomena of 
peritonitis are at first generalized, with retraction of 
the belly, general sensibility of the abdomen, 
collapsus, and coldness of the extremities. Then 
little by little the phenomena are seen to amend, to 
become localized towards the right side of the belly, 
while the painful tumefaction plainly manifests 
itself in this region. 

It would seem, then, that two varieties of onset 
must be admitted: the one where the peritonitis, 
more or less limited at first, tends to spread farther 
and farther — progressive peritonitis; the other where 
the peritonitis, at first generalized, tends to retro- 
cede, becoming localized, regressive peritonitis. 

But it is very difficult to say whether in this 
second case there is really general inflammation of 
the serosa, or whether we have to do simply with 
sympathetic phenomena of nervous irritation, propa- 
gated at first all over the peritoneum, then 
disappearing at the end of several days, only to give 
place to signs really due to local inflammation. 

During this phase constipation is the rule, some- 
times going so far, when meteorism is marked, as to 
simulate an obstruction. In other cases there is 
alternation of liquid stools and of faecal retention. 
Later, when the purulent collection is very limited, 
a, continual diarrhoea may be observed; but most 



— 106 



often lavements are necessary to empty the inert 
intestine. 

The fever is likewise very variable. To judge 
from the published reports, which are not very ex- 
plicit in this regard being generally cases put on 
record by surgeons who give few details except 
with reference to the operation, the fever is not high, 
not exceeding 39° C. ; in a small number of cases it 
is normal or nearly normal at the moment of opera- 
tion, about the seventh or eighth day. 

In a case which I have just observed, the fever 
pursued the following course: During the first' three 
days which followed the perforation, the temperature 
oscillated between 39° C. in the morning and 40° to 
40.6° in the evening. At the end of the fourth day 
it fell to 38.6°-38.8°, to oscillate the sixth, seventh, 
eighth and ninth days between 38° and 38.5°. The 
tenth day it rose again to 39.2° in the morning, 40° 
in the evening, remaining on the following day 
between these figures. Then the operation was per- 
formed by M. Richelot, with discharge of a great 
quantity of turbid serous and fetid pus. It seems, 
then, that there was, after the initial febrile inflam- 
matory invasion, a period of almost apyretic remis- 
sion, followed about the t£nth or eleventh day by a 
new rise of temperature. 

But it would need new observations carried 
farther to decide: first, whether this course of the 
fever is habitual; and in the second place, whether 



— 107 — 

this thermic ascension is due to a new peritoneal 
invasion, or, on the contrary, to the resorption of 
septic products, or finally, to purulent transforma- 
tion of the exudation. But we cannot any longer 
admit, as a general rule, this last hypothesis; if it 
may be true in the case of acute non-perforative 
appendicitis, it is certain — and the early operations 
prove it — that 48 hours after the perforation has 
taken place there already exists, though in small 
quantity (not more perhaps than a few spoonfuls), 
fetid pus in the peritoneum in the neighborhood of 
the diseased appendix. 1 

Whatever may be the course of the fever (a ques- 
tion still not precisely settled, but waiting further 
observations), it is on the character of the iliac 
tumefaction that we must mainly rely. 

a. Characters of the Purulent Collection, — At what 
moment does it first appear ? or, at least, is it 
perceptible by palpation ? The period is quite 
variable; the meteorism on the one hand, the mus- 
cular tension and the pain on the other, often prevent 
exploration. It may be admitted that the tumor 
becomes appreciable between the second and the 
seventh day. In twenty-four cases collected by 
Fitz, where this detail is noted, the following dates 
are observed: 



1 Ina case published by Peckham {Boston Med. and Surg. Journal, 
1882, p. 159), where the patient succumbed on the fifth day, there was 
found in the iliac fossa an encysted peritonitis containing nearly three 
pints of fetid pus. 



— 108 — 

Second day 3 times. 

Third " 4 

Fourth " 2 

Fifth " 4 

Sixth " 5 

Seventh " 4 

Besides, in one case the tumor could be felt from 
the first day, and in another only on the eighth. 

We must not expect always to find a limited tumor; 
in some cases, however, in the first two or three days 
there may be felt a small, elongated, oval mass, in the 
right iliac fossa (several observations of Roux, of 
Lausanne). In one case, it is said that the patient 
herself had, on the second day, felt a little globular 
swelling in her right fossa. 

But this is extremely rare, and usually the tumor is 
formed not only by the sac in which the pus accumu- 
lates, but also by the neighboring intestinal coils, 
agglutinated by plastic peritonitis developed in the 
vicinity. It is the extension of this perityphlitic 
peritonitis which makes the volume of the tumor, and 
not the mere size of the purulent collection. The 
tumefaction may indeed occupy the entire right half 
of the abdomen, rising even above the umbilicus, and 
nevertheless the abscess properly so-called will not 
exceed the size of the closed fist. When the omen- 
tum is inflamed and thickened, the dimensions of the 
tumor may still be considerable. 

It is then rather a diffuse puffiness, more or less 



— J 00 — 

extended, than a veritable tumor which palpation re- 
veals. One may, however, according to Roux of 
Lausanne, when the abdomen is not too painful or re- 
sistant, feel a clearly defined ovoid tumor, parallel to 
Poupart's ligament and rising more or less above the 
iliac crest; this is observed especially when the 
appendix is situated directly below the caecum. 

Percussion over this tumefaction gives a slight 
degree of dullness, sometimes even complete dullness 
in certain points; but in the immediate neighborhood 
a tympanitic sound is obtained which may obscure 
the dull sound. The intestinal coils, distended and 
agglomerated, account for this tympanism, which may 
be due in certain cases to the presence of gas in the 
pus cavity. 

Rectal exploration must be practised with care in 
all cases of appendicitis. With this, in the case of a 
woman, the vaginal touch must be associated. Dur- 
ing the first few days, doubtless this investigation 
will furnish but little information, although, accord- 
ing to Treves, one may thus succeed in feeling 
the dilated appendix. But when the pus accumulates, 
especially if it tends to point towards the pelvis, a 
more or less hard or fluctuating tumefaction may be 
detected. 

The relations of the appendix explain certain 
accessory symptoms which may be observed in the 
course of this localized peritonitis; such, for instance, 
as the painful irradiations towards the thigh or 



110 



towards the testicles, the impairment of motion of 
the right lower extremity, the tenesmus or frequent 
desire to urinate. 

b. Modes of Termination. — In default of surgical 
intervention, how does this suppurative peritonitis 
terminate? May it resolve and get well by resorption? 
Although some affirm this, and although Renvers 
pretends to have seen several patients completely 
cured by medical means, in whose cases an explorative 
puncture had revealed the presence of pus, 1 I strongly 
doubt whether the putrid and fsecaloid pus which re- 
sults from the perforation of the appendix may ever 
be completely resorbed. It is possible, if the puru- 
lent collection is very small, that this pus may be 
encysted and remain inoffensive for a certain time. 
But a recurrence is, so to speak, fatal in such a case; 
and these little juxta-appendicular foci, in acting as 
an inflammatory thorn, are, as we shall soon see, the 
anatomical cause of one of the varieties of recurrent 
appendicitis. 

If the case be left to itself or to purely medical 
treatment, the modes of termination may be: 

1. A diffuse peritonitis, rapidly fatal, either by 
simple extension of the local inflammation, or, after a 
variable period, on the occasion of a strain, of a too 
energetic exploration of the abdomen, etc., by the 
giving way or rupture of the plastic barrier formed 
around the purulent focus. 



Society of Internal Medicine of Berlin, session of January 23d, 1891. 



— Ill — 

2. One of the extraordinary complications which 
we have cited above: ulceration of a blood-vessel, 
large vein or large artery of the region, with haemor- 
rhage, or pylephlebitis giving rise to abscesses of the 
liver; purulent extension toward the diaphragm, with 
perforation and purulent pleurisy or pneumonia. 

3. Bursting of the purulent collection, either ex- 
ternally or into one of the neighboring cavities, 
caecum, rectum, bladder, vagina. 

From the point of view of the relative frequency 
of these different terminations, Bull 1 has collected 
statistics of sixty-seven cases, with the following re- 
sults : 

Bursting externally 28 cases. 

' ' into the caecum 15 " 

" " " rectum 2 " 

" " bladder 2 " 

" " internal iliac artery 2 " 

" " thoracic cavity 2 " 

Death by pyaemia 8 " 

In these statistics, the frequency of cases where 
the opening is external is evidently abnormal. In 
another statistical compilation (that of Paulier), in 
forty-six cases this termination is recorded as occur- 
ring only four times, while in fifteen the abscess 
opened into the caecum. 2 

But whether the abscess opens externally or inter- 



1 Bull, New York Acad, of Medicine, January 8, 1875. 
a Paulier. These de Paris, 1875. 



— 112 — 

nally, there may be trouble. If the opening be on 
the outside, there ordinarily remains a fistula, which 
is long in closing. If it opens into the vagina, blad- 
der, or intestine, the patient may indeed rapidly get 
well, but death by putrid infection and exhaustion is 
also possible. 

19. Subacute Appendicitis. 

Perforative appendicitis is ordinarily an acute affec- 
tion, with sudden and well-defined onset and a con- 
tinuous progress, ending in the course of ten to 
fifteen days either in death, or in the formation of a 
purulent collection, which is limited and easy of 
detection. But it is not always so, and the disease 
may take on from the onset, or at some subsequent 
time, a slow, insidious, and deceptive course. These 
are the cases which we group under the name of sub- 
acute appendicitis. 

Anatomically we may explain these cases in two 
ways: either the perforation takes place into the 
retrocecal cellular tissue, the appendix being embed- 
ded in the cellular tissue and no longer free in the 
peritoneum, and the pus steadily infiltrates (without 
being at once collected into a limited abscess) the sub- 
peritoneal tissue or muscles of the region; or it may 
be that the appendix, prior to the actual crisis or 
during the first days of the sickness, becomes isolated 
by sufficient adhesions, from the great peritoneal 
cavity, and the perforation takes place in the midst 



— 113 — 

of these adhesions, in a sort of recess well walled 
in, where the pus accumulates without very marked 
inflammatory reaction. 

From a clinical point of view, sometimes it is the 
general or subjective symptoms which are lacking 
or are ill-defined, while the local lesions progress 
quite rapidly and with the ordinary characters of 
appendicitis; sometimes, on the contrary, the general 
symptoms are present, but the local signs remain 
obscure, difficult to perceive, so that one- will some- 
times have the impression of a grave affection, of a 
deep suppuration, without being able to localize it. 

I shall then make three varieties of subacute 
appendicitis: 

1. Cases where the affection has a sudden onset, 
but where the symptoms are from the first insidious, 
little marked, or latent, the local peritonitis terminat- 
ing rather rapidly with grave accidents; 

2. Cases where the appendicitis has an acute and 
violent commencement, but soon calms down to give 
place to local and general phenomena ill-defined and 
difficult to interpret; 

3. Cases where all is insidious and obscure, the 
onset, the general signs, and the local symptoms. 

A. First variety. — Cases of this kind are only sub- 
acute subjectively, if we may use the expression; but 
the course is as rapid and continuous as in acute 
appendicitis. There is nothing to alarm the patient 
or the physician, neither violent pain nor intense 

8 



— 114 — 

fever, and yet in a few days a purulent collection 
forms and may kill the patient before the diagnosis 
has been determined. 

Fitz relates a case of a sailor who, in a voyage 
from Portland to New York, felt a pain in the right 
iliac fossa. He took a purgative, and, although 
suffering, continued to do service during all the fol- 
lowing week. He then 'returned to Boston for 
treatment 13 days after the onset of the pain, but 
died the next day, and at the autopsy the appendix 
was found gangrenous, and there was an abscess in 
the right iliac fossa. 

A man aged 42 years, observed by Roux, was 
taken without any known cause with pains localized 
at first in the right iliac fossa. But these pains were 
at first of so little violence that they did not prevent 
him from continuing his work as carpenter for a 
whole week. There were neither digestive troubles 
nor constipation. At the some time, these pains, 
which at first consisted in a little discomfort, 
became more intense about the eighth day, and 
obliged him to take his bed. Tongue was coated 
and there was some vomiting. The next day the 
patient felt better; pulse 92. Belly not tympanitic; 
little tender to pressure except in the ileo-caecal 
region, but pressure also caused pain in the left iliac 
fossa. No very perceptible tumor was felt, nor any 
local bulging. 

Roux at the same time did not hesitate to diagnos- 



— 115 — 

ticate an appendicitis with perforation, and to make 
an incision. There was a flow of pus, serous in 
character, clear and grayish, which seemed to be 
free in the abdominal cavity. The finger, introduced 
deeply into the wound, felt the appendix below the 
caecum; it was embedded in a sort of pouch formed 
of peritoneal adhesions, and was extracted in 
gangrenous shreds, with a stercoral calculus in its 
cavity. The results of the operation seemed to be 
good; the temperature did not rise above 38° C, 
but the fifth day the patient died suddenly of a pul- 
monary embolus, which probably originated in one 
of the deep veins of the pelvis, inflamed and throm- 
bosed — which seems to indicate that the purulent 
inflammation must have silently progressed farther 
and deeper than the incision made by the surgeon; 
the autopsy, however, was not made with sufficient 
care to demonstrate this. 

B. Second variety. — In this category of cases the 
affection begins as suddenly as in the acute form, 
either by a crisis of appendicular colic, or, after 
several vague attacks of pain, by a sharp pain in the 
right iliac fossa. This sudden onset, complained of 
by the patient, should be the signal of alarm. But 
on the following days the pain abates or goes away 
altogether; no very clear abdominal symptom 
attracts attention; meteorism, resistance to pressure, 
muscular retraction, tenderness on pressure, are 
absent; the temperature remains normal; and it is 



— 116 — 

only at the end of 8, 10, or 15 days that fever 
appears, irregular, intermittent, accompanied or not 
by obscure pains in the right side. 

If the appendicitis thus manifests itself in an 
individual of a certain age, subject to abdominal 
suffering or convalescing from some acute disease, the 
physician's hesitation to affirm an abscess due to 
intestinal perforation is easily understood. As pal- 
pation reveals only an obscure swelling in the caecal 
region, the probability of a simple faecal engorge- 
ment will be likely to be entertained; the fever will 
be ascribed to some gastric or other digestive 
disturbance. In short, the medical attendant will be 
lulled into a fancied security till the gravity of the 
situation at last compels a correct diagnosis. 

[In the original a long report follows of the cele- 
brated case of Gambetta, for which we have room 
for only the outlines^ 

December 8th, 1882, Gambetta complained of 
severe pains in the belly. December 9th, the same 
pain, with nausea. In the evening, while at stool, 
an intense pain in right loin, lasting a part of the 
night. December 10th, pain is less sharp; anorexia; 
coated tongue; no tumefaction over belly; little 
tenderness on pressure over right iliac fossa; 
temperature remains normal. 

December 11th, 12th, 13th, and 14th, patient felt 
quite well; was up and dressed; ate his meals with 
a fair appetite. 



— 117 — 

December 15th, discomfort in the abdomen and 
frequent eructations. A short walk in the park. In 
the evening an uncomfortable sensation of heat 
without a chill. 

December 16th, was taken at dinner with violent 
colic; nevertheless rode out. In the evening another 
hot spell without chill; temperature rises to 39° C. 

December 17th, temperature keeps at 39° C; a 
slight swelling is found in right iliac fossa. 
Diagnosis, typhlitis. 

December 18th, violent chill in the evening; tem- 
perature 39.9° C. 

December 19th, new and repeated chills; two 
fingers' breadth above the right iliac spine a painful 
elongated and cylindrical tumefaction is felt on deep 
pressure. 

The following days he had several chills, but felt 
better. General condition seemed to improve. The 
swelling in the right side increased. A large blister 
was applied over the swelling on the 23d. Decem- 
ber 27th the symptoms all became worse. An attack 
of erysipelas followed the application of the blister, 
and spread over all the right side afld even down the 
thigh. The patient succumbed December 31st. The 
autopsy revealed the appendix directed vertically 
above and behind the csecum, perforated in two 
places, and floating in a sanious pus. The perfora- 
tion had taken place in the retro-csecal cellular tissue, 
and had caused the formation of a vast focus of 



— 118 — 

purulent and gangrenous infiltration, extending up 
to the kidney in one direction and to the vertebral 
column in another. 

This case illustrates the insidiousness of the march 
of some cases of perforative appendicitis with 
localized purulent collection. For several days 
Gambetta was so comfortable as to think himself 
almost well. The diagnosis of stercoral typhlitis 
with subsequent propagation of the inflammation to 
the peri-ca3cal tissue, was in accordance with the 
notions of the time. An early operation might 
possibly have saved this great man. 

G. Third variety. — This third variety includes 
cases where all is obscure and deceptive — the onset, 
the local signs, and the general symptoms. The 
attack may come on in a subject of apparently good 
health; but generally, like cases of the preceding 
variety, the patient has been for a long time suffer- 
ing from vague intestinal troubles, or is convalescent 
from some acute disease. 

There is neither clear onset, nor fixed pain attract- 
ing attention to the iliac fossa. The affection 
begins merely by digestive troubles, want of 
appetite, vomitings, saburral tongue, constipation; 
the patient complains of dull colicky attacks, of 
some distension of the abdomen; there is no fever, 
or if there is any it is very slight; there is nothing 
to indicate any lesion of gravity. Moreover, the 
exploration of the abdomen reveals nothing to cause 



— 119 — 

alarm; deep pressure in the right loin is a little 
painful, but there is not excessive sensitiveness in 
that region, and the pain is like that experienced at 
other times by the same patient, either in the hypo- 
gastrium or in the left iliac fossa. The patient may 
continue to walk about and attend to his business. 

In short, everything is calculated to relieve both 
patient and physician of anxiety and alarm, and 
danger is not apprehended till the appearance of 
remittent or intermittent febrile attacks, preceded or 
not by chills, announces, not indeed suppuration, for 
that has already been going on for some time, but 
probably the commencing infection of the organism. 

Then, for the first time, the conviction is forced 
upon the medical attendant that he has to do with a 
deep purulent collection; and it would seem that the 
local signs, the more or less well defined swelling in 
the right iliac fossa, the especial sensitiveness of that 
region when deep pressure is made and the history 
of colicky pains, ought to be enough to put a wary 
practitioner on the right track. 

But it is easy to understand that the most accom- 
plished physician will sometimes fail to early 
diagnosticate these cases. When you think that it 
is in these insidious forms that purulent infiltrations 
take place, along the psoas, down into the pelvis, 
upward toward the kidney and diaphragm; that it 
is in these same deceptive forms that the abnormal 
complications of which we have spoken occur — the 



— 120 — 

thrombosis of the iliac veins, with pulmonary 
embolism; thromboses of the radicles of the portal 
vein with pylephlebitis, hepatic emboli and abscess 
of the liver, perforation of the abscess through the 
diaphragm into the pleura, with purulent pleurisy of 
the right side, and even of the left side, you will 
understand how easily the physician may be misled, 
especially if the disease has not been followed from 
its onset, and that it becomes more and more difficult 
for him to refer to their true cause phenomena so 
distant from the primary seat of the lesion. 

Hence, we are warranted in asserting that next to 
hyper- acute perforative appendicitis with general 
peritonitis, sub-acute appendicitis is the most grave 
and formidable form of appendicular inflammation. 

20. CHRONIC RECURRENT APPENDICITIS. 

This form of appendicitis, called relapsing or 
recurrent, is one of the most interesting and import- 
ant, though hitherto no full and connected 
description of it has been given; its importance 
being largely due to the fact that it was for this 
variety that the operation of excision and ablation of 
the appendix (an operation to be performed in the 
interval of two acute crises) was first proposed. 

The name of chronic relapsing appendicitis ought 
to be reserved for cases where the relapses succeed 
each other very rapidly and at short intervals. 



— 121 — 

Cases where the attacks are repeated at very long 
intervals, being a year or more apart, are only 
recurrences, each crisis constituting of itself the 
whole disease, and not being necessarily dependent 
on any former attack. These previous attacks may 
be valuable data from a diagnostic point of view, 
and they may be an influential predisposing cause, 
but they do not justify us in making of these cases, 
occurring with such long intervals, a special clinical 
type, for apart from the recurrence, there is nothing 
to differentiate these from ordinary cases of appen- 
dicitis. 

It is not so with recurrent appendicitis, properly 
so called. The latter has a course, modes and 
symptoms which are peculiar to it; it is really a 
chronic disease with successive attacks. 

The radical and systematic treatment practised by 
the Americans has taught us what are the lesions 
which form the anatomical substratum of this variety 
of appendicitis. These lesions are generally those of 
a chronic inflammation affecting at once the mucosa 
of the appendix, its walls, and its peritoneal covering. 

The appendix is thickened and dilated; the dila- 
tion may be considerable, giving to the organ the 
size of the thumb; its cavity is then filled with a 
thick and abundant mucus. Sometimes, in conse- 
quence of a flexion of the appendix, or of a partial 
constriction of its cavity consecutive to a cicatrized 
ulceration, the extremity alone is dilated. In this 



— 122 — 

case, the tension of the imprisoned liquid on the one 
hand, the thickening of the walls on the other, may- 
give the sensation of a solid mass. In an observation 
of Treves, the extremity of the duct was so widened, 
so indurated, so perfectly rounded, that it seemed to 
contain a stercoral concretion. The appendix was 
bent on itself; on liberating and straightening it, 
the mucus flowed back into the caecum and the 
appearance of a solid tumor at once disappeared. 
This flexion of the appendix, maintained by peri- 
toneal adhesions, is a condition often noticed; it 
explains the retention of mucus which the mucosa 
continues to secrete and which cannot flow off into 
the caecum. 

In other cases, there is no dilatation; the appendix 
seems, however, to be transformed into a fibrous cord 
by the thickening of the walls, the canal being 
reduced to a narrow slit. It is then almost com- 
pletely buried in the midst of adhesions, which are 
generally very resistant, the remains of repeated 
attacks of adhesive peritonitis. These adhesions not 
only involve the appendix, but also the neighboring 
intestinal coils and the omentum, a part of which 
may be found fixed in the iliac fossa, and give to 
palpation the feel of a tumor. 1 The plastic exuda- 
tion may be so abundant, the adhesions so numerous 
and resisting, that the ablation of the appendix is 
rendered extremely painful and difficult. 

1 Case of Teale. Recurrent typhlitis. Brit. Med. Jour., January, 1891 



— 123 — 

Finally, there have been rare cases where the 
appendix is found perforated, with a little juxta 
appendicular abscess, containing one or two spoon- 
fuls of faecaloid pus and a small stercoral concretion. 
Dr. Lecorche has communicated to me an instance 
of this kind which he recently observed. A man, 
aged 28 years, had had nine relapses in the space of 
20 months. He presented himself at the Hospital 
Dubois earnestly demanding an operation. This 
operation, made by Dr. Potherat, disclosed a per- 
forated appendix communicating with a little pus 
cavity, and in this cavity a stercoral concretion kept 
there by adhesions. 

How, according to these anatomical findings, shall 
we explain the repetition of the crises and the 
mechanism of the relapses? It is very probable that 
the cause of the paroxysms is not the same in all 
cases. 

According to Treves, it is to the retention of the 
mucus in the appendix that the recurrent appendi- 
citis is due. But Treves does not explain how this 
retention can provoke a painful paroxysm, accom- 
panied by vomitings and peritoneal symptoms. 

In my opinion, the partial or total distention of 
the cavity of the appendix by the mucus may serve 
to explain a certain number of facts. The mechan- 
ism of the crisis appears to me to be the same as in 
appendicular colic by the engagement of a stercoral 
concretion. The emprisoned mucus steadily dilates 



— 124 



the appendix; at a given moment this dilatation 
attains its maximum and causes painful contrac- 
tion of the muscular coats of the appendix, hence 
the acute abdominal pain follows as the reflex 
consequence. As we have to do only with a liquid 
and not with a hard body compressing the blood 
vessels of the wall in such a way as to prevent 
nutrition, the appendix does not tend to become 
perforated; the muscular contraction has the effect 
of expelling the liquid towards the narrowed part, 
and the obstacle being formed solely by the bending 
or stenosis of the duct, the mucus passes slowly and 
little by little through the narrow passage, and is 
voided into the caecum. 

But not all cases are explicable in this way. Very 
often there exists no retention of mucus, nor any 
trace of stenosis, or flexion of the appendix, which 
could at any moment have given rise to such 
retention. The appendix is everywhere thickened 
by chronic interstitial inflammation of its walls. 
The painful crises, however, have not been less 
intense, nor less frequent. I think that the relapse 
in such cases must be explained by the temporary 
engagement of a stercoral calculus, which provokes 
the painful manifestations and an acute attack of 
parietal appendicitis by the mechanism which I have 
already described so fully. The expulsion of the 
scybalum into the csecum, in consequence of the 
contraction of the appendix, brings about the end 
of the crisis. 



— 125 — 

On the other hand, the frequent observation of 
evident signs of chronic peritonitis, of peri-appen- 
dicular adhesions, of thickening of the peritoneum 
over the neighboring intestinal coils, shows that, in 
a number of cases, the recurrence must have for its 
cause an acute attack of plastic appendicular 
peritonitis, spreading more or less around the caecum 
and into the right iliac fossa. Finally, when there 
is found in the neighborhood of the perforated 
appendix a small focus of pus containing a stercoral 
concretion or debris of faecal matter, whether or not 
the first crisis is due to the engagement of this con- 
cretion in the appendix, it is reasonable to assign the 
consecutive attacks to a sort of rekindling of 
peritoneal irritation by the presence of this faecaloid 
pus; the symptoms may be more or less grave % and 
the duration of the relapse more or less prolonged, 
according to the extension taken by this inflamma- 
tory recrudescence. 

It is seen that the study of the facts hardly 
permits us to assign the same mechanism to all 
relapses of appendicitis. Hence there are necessarily 
some clinical differences in the characters and course 
of the acute attacks, differences which may also be 
noticed in the period between the relapses. We 
will describe successively these two phases of chronic 
appendicitis, 

a. The relapse. — We need not dwell at length on 
the symptomatology of the relapse. In fact, it does 



— 126 — 

not essentially differ from that of one of the forms 
of appendicitis which we have described. It may be 
purely appendicular; it may be peritoneal; it may 
be suppurative. 

The first two forms are the most frequent. They 
correspond either to an intermittent distention of the 
appendix by mucus or to the temporary engagement 
of a scybalum, or to an acute attack of plastic peri- 
appendicular peritonitis. 

In the first two alternatives, the symptoms are 
those of simple parietal appendicitis with appendic- 
ular color. The attack, which is sometimes of 
extreme violence, sometimes mild and characterized 
only by dull pains most felt in the right side, is 
followed by a fixed pain in the right iliac fossa, with 
a certain degree of resistance of the abdominal wall 
at this point. This resistance yields at the end of 
several days, and on exploring the region the 
physician may ordinarily feel, when the appendix is 
not deviated backwards or too far inwards, an 
elongated mass of the size of the thumb or index 
finger, which clearly gives the sensation of the dis- 
tended appendix. This painful elongated tumor 
may remain perceptible in the interval of two crises, 
though it notably diminishes in volume. Whenever 
this can be felt, we are certain that the patient is not 
fully recovered and that he is exposed to a new 
attack. 

The duration of each relapse of this moderate type 



— 127 — 

hardly exceeds eight or ten days. But the crisis 
may be shortened or aggravated, though remaining 
strictly appendicular, and take on either the painful 
purulent form, with appendicular colic, or the pseudo- 
peritoneal form with intense peritonism, as we have 
indicated above (see paragraph 17). 

The following observation, which we borrow from 
Treves, will give a sufficient idea of this ordinary 
form of recurrent appendicitis. 

A man, aged 44 years, entered the hospital in 
May, 1890. He had been sick since April, 1889. 
Previously his health had been perfect. He was a 
vigorous man, never having suffered from dyspepsia, 
and his intestines had always regularly performed 
their functions. 

In April, 1889, he was taken with abdominal pains 
without appreciable cause. These pains gradually 
increased and soon he presented all the characteristic 
signs of an appendicitis — distention of the abdomen, 
repeated vomitings, constipation, painful tume- 
faction of the right iliac fossa. This attack 
terminated happily. But since then he had not 
ceased to have new attacks at intervals of five or six 
weeks. The acute period of each relapse lasted from 
five to seven days. After the cessation of acute 
symptoms, he entered upon a period of slow con- 
valescence, but before he could call himself entirely 
•cured a new attack supervened. 

This man had not been able to work for thirteen 



— 128 — 

months. The most rigorous precautions could not 
prevent the repetition of the relapses. These re- 
lapses seemed to increase in gravity, and the patient 
had become a valetudinarian. He naturally had the 
fear of a new attack, and he had come to believe that 
he could not survive another. The day before the 
operation there was discovered in the right iliac 
fossa, on palpation, a little above and outside of 
Poupart's ligament, an appendix very much dilated. 

The next day the appendix was excised; it was 
twisted on itself, very much deformed and distended 
so as to form a rounded mass. The operation 
presented no difficulty; the recovery was speedy and 
uninterrupted, and five months afterwards the 
patient was found to be in good health. 1 

The peritoneal form differs from the preceding 
only in the greater intensity of the local symptoms, 
due to the propagation to the surrounding serosa of 
the appendicular inflammation, and to the greater 
duration of the acute attack. I need not repeat what 
I have said of this form of appendicitis with partial 
plastic peritonitis. 

These are the two principal aspects under which 
the relapses occur. The suppurative form is much 
more rare. But I cannot admit with Treves that 
" when an abscess forms and the patient gets well, 
he is no longer exposed to other attacks." 



1 Treves. The surgical treatment of typhlitis. Wood's Monograps 
August, 1891. 



— 129 — 

We have above cited a case where a little juxta- 
appendicular purulent focus gave rise, in a year and 
a half, to nine relapses. It is true that in this case 
none of the relapses ended in the formation and 
evacuation of a real purulent collection. 

I have seen, in consultation with Dr. Juhel Renoy, 
another patient who in a year had four attacks of 
appendicitis. Each time the attack ended by the 
formation of an abscess in the iliac region, which 
pointed above Poupart's ligament, and which each 
time necessitated a surgical operation, giving vent to 
a great quantity of horribly fetid pus. 

Treves says that the evacuation of the pus proba- 
bly occasions the suppression of the veritable cause 
of the suppuration, the faecal concretion being 
evacuated with the pus, or the appendix, seat of the 
lesion, being destroyed by gangrene. 

It may be seen, by our first observation, that the 
suppuration may not be sufficiently intense to burst 
externally, or to indicate the necessity of bistoury, 
and that the faecal concretion may remain imprisoned 
in the false membranes. It is seen in the last case 
which I have cited, that the repeated evacuation of 
the abscess does not necessarily bring to the surface 
the cause of the suppuration, since on four occasions 
the purulent collection formed again under the same 
conditions. 

b. Intermediate period. — The acute crisis being at an 
end, the patient tends gradually towards health. But 



— 130 — 

he never recovers completely. When the appendi- 
citis is purely parietal the remission may appear 
complete after the first two or three attacks, the 
intestinal symptoms remaining inconsiderable and 
the general state being satisfactory. 

But from the third or fourth relapse, often earlier, 
the patient continues to suffer, and certain local 
signs persist, which the physican may find by search- 
ing if the patient does not speak of them, and which 
at last tell gravely on the general health. 

Vague abdominal pains, frequent colics, occasional 
distention of the abdomen, painful digestion, a sense 
of discomfort in the right iliac fossa showing itself 
when fatigued, when walking, when lifting, etc., 
alternations of constipation and mucous stools — such 
are the principal symptoms which the patient com- 
plains of. 

The exploration of the iliac fossa reveals a fixed 
focus of pain, which is aggravated and intensified by 
pressure of the finger, over the middle of a line ex- 
tending from the umbilicus to the antero-superior 
spine of the ilium; and if the abdominal wall is 
strongly depressed, there is felt at this point a little 
elongated mass, more or less sensitive, which rolls 
under the finger, and which is the thickened and 
dilated appendix. 

But the most important consequences of chronic 
appendicitis, whether the inflammation be only 
parietal or whether the appendix be imprisoned in 



— 131 — 

peritoneal adhesions, affect the functions of the 
caecum and large intestines; so that it may be said 
that, if the relapse is chiefly appendicular, the inter- 
mediate period is rather caecal or at least intestinal. 

The inflamed appendix, in fact, acts as a foreign 
body, irritating not only the peritoneum, which is in 
a constant state of threatened inflammation, but also 
the large intestine, whose troubles may be of a 
catarrhal or mechanical order. 

Indeed, the repeated relapses end by bringing on 
more or less rapidly, sometimes, a marked atony of 
the caecum, sometimes a chronic irritation of the 
mucosa of the caecum and of the colon. 

1. Atony of the ccecum. — Caecal atony implies a 
paretic condition of the muscular layer. This 
paresis may be explained in several ways: by nervous 
exhaustion, consecutive to repeated excitations of 
the appendix, or, in accordance with the law of 
Stokes, to the paralysis of the muscular planes sub- 
jacent to the inflamed serosa or mucosa, Whatever 
may be the true cause, the muscular atony of the 
caecum manifests itself either by stagnation of the 
faecal matters in this part of the large intestine, a 
stagnation which may amount to a real stercoral en- 
gorgement, or, as is generally the case, by gaseous 
distention of the organ. 

Whatever the old writers may say, an isolated 
stercoral engorgement of the caecum giving rise to a 
clearly defined cylindrical tumor is a rarity. But if 



132 — 



this stercoral tumor really ever exists, it is for the 
most part in relapsing appendicitis that it will be 
observed. Yet, doubtless, even in relapsing appen- 
dicitis, this stagnation of faecal matters is very rarely 
sufficiently pronounced to give one a clear sensation 
of a csecal tumor. The stercoral tumors are oftener 
seated in the left iliac fossa, or in the transverse 
colon. 

Gaseous dilatation is much more frequent. It 
manifests itself by an exaggerated tympanitic 
sonorousness in the region of the right iliac fossa, 
often accompanied by gurgling sounds which may be 
elicited by pressure. I once saw a patient affected 
with recurrent appendicitis in whom the gaseous dis- 
tention of the caecum presented particular characters. 
In the interval of the acute attacks the belly 
remained painful to pressure, especially on the right 
side; on pressing deeply a very marked gurgling 
sound was heard, then at the end of a few seconds a 
soft tumor was seen to form in the right iliac fossa, 
swelling to considerable size under the finger; this 
tumor could be easily emptied by pressure, with a 
marked glou-glou sound. The patient, moreover, 
had remarked that this soft tumefaction had formed 
from time to time spontaneously; to cause its dis- 
appearance he had only to press strongly over his 
belly, when it would subside with a noise like that 
-of pouring water out of a bottle. 

2. Chronic intestinal catarrh. — The atony of the 



— 133 — 

caecum ordinarily coincides with a greater or less de- 
gree of chronic irritation of the large intestine. We 
have now the symptoms of mucous colitis: dull, col- 
icky pains, habitual distention of the abdomen, at- 
tacks of obstinate constipation, followed by diarrhoea 
and glairy and painful stools. It is not always easy 
to decide whether these intestinal troubles are anter- 
ior or posterior to the first attack of appendicitis. 
We have said that mucous colitis in numbers of cases 
must be regarded as a predisposing cause of inflam- 
mation of the appendix. What is certain, is that the 
signs of this colitis are observed chiefly in relapsing 
appendicitis in the interval of the crises. 

In proportion as the relapses become more numer- 
ous, the consequences of these intestinal troubles in- 
crease in gravity. In certain cases, a chronic diar- 
rhoea is established. No longer well nourished, suffer- 
ing from bad digestion, tormented by continual 
abdominal pains, by irregular attacks of fever, these 
patients lose strength, grow pale and thin, take on 
an earthy hue and arrive at a state of intestinal 
cachexia, which finally gives them the appearance of 
persons affected with tuberculous peritonitis or ab- 
dominal cancer. 

C. General course of the disease. — Thus constituted 
by acute crises separated by intervals of relative 
calm, relapsing appendicitis is a disease of long dura- 
tion, but how long it is hard to determine. Can it 
get well spontaneously or by medical treatment alone? 



134 — 



Must it necessarily end in cachexia or fatal exhaus- 
tion of the patient? May it end in a perforation which 
entails death? I 4 t is hard to give a positive answer to 
these questions, from the fact that the final result of 
all the cases published of late years is an operation, 
which, by removing the appendix, removes the cause 
of the accidents, and consequently cuts short the 
natural course of the affection. 

It is quite possible that recovery may take place 
without surgical intervention, by a fibrous transform- 
ation of the appendix, which, under the influence of 
these repeated inflammatory attacks, is contracted, 
obliterated, and becomes a simple cord of cicatrical 
tissue. 

On the other hand, we know of no case terminating 
fatally by cachectic exhaustion, although the reading 
of certain reported observations might warrant the 
presumption of such a termination, if the disease 
were left to itself. 

As to the possibility of perforation, there exist two 
diametrically opposite opinions. Some declare that 
it is not common for a first attack of appendicitis to 
end in perforation, and that we ordinarily find in the 
antecedents of persons affected with perforative ap- 
pendicitis the mention of one or more previous attacks 
of mild appendicitis. Others maintain that several 
attacks are a safeguard against perforation, and that 
the more frequent the recurrences, the fewer the 
chances of this fatality. 



— 135 — 

The first opinion is not tenable as a general rule. 
Fitz's statistics, which deal with 257 cases of perfor- 
ative appendicitis, show only 28 cases, i. e. a propor- 
tion of 11 per cent., where less grave crises have 
preceded the fatal perforation. Kraft's statistics, 
the most favorable to this view, give only a propor- 
tion of 25 per cent. We must then admit that in at 
least 75 per cent, of cases, the first attack may be 
perforative. 

But we must not lose sight of the fact that writers 
do not always make distinction between recurrence 
and relapse. And we have shown that in good nos- 
ology this confusion cannot be countenanced. We 
should no more confound relapsing appendicitis with 
the recurrences of appendicitis than relapsing typhoid 
with a recurrence of typhoid fever. 

Certainly we note quite often in the previous his- 
tory of a case of perforative appendicitis the existence 
of former attacks of simple appendicitis, but this is 
by no means generally the case, and it is noteworthy 
that precisely the gravest form, hyperacute appendi- 
citis, most often supervenes in the midst of perfect 
health, with nothing to hint at the possibility of such 
a fatality. 

In true relapsing appendicitis, every attack does 
doubtless give some guaranty against danger. The 
oftener the relapses, the less the probability of per- 
foration. If the crisis is simply appendicular, each 
inflammatory attack tends to thicken the walls of the 



— 136 



appendix, to infiltrate them with fibrous tissue, and 
thus render them less likely to be a prey to the ulcera- 
tive depredations of microbes. If the relapses are 
due to outbreaks of peritonitis, the barrier formed by 
adhesions and plastic exudates is re-enforced each 
time, and if by chance a perforation does take place, 
it will not have any serious consequence, the appen- 
dix being well protected in its fibrous investments, 
walled off from the general peritoneum, and isolated 
from neighboring organs and tissues. 

Relapses may, then, take place indefinitely, with 
no especial menace of perforation. The frequency, 
the interval, the intensity of the attacks are very 
variable. They reappear sometimes with a remark- 
able regularity, every three weeks, every month, 
every two months. At other times the intervals are 
longer. In certain cases the patient, after a series of 
crises, remains three or four months or longer with- 
out a relapse, then the attacks reappear. 

The duration of an attack is about eight days, but 
it may be shorter, two or three days. In general 
the relapse is reproduced after the same type and 
this type is that of the initial attack. But the type 
may vary, and with crises of parietal appendicitis or of 
simple appendicular colic, there may be more intense 
attacks with acute outbreaks of partial peritonitis. 

But if relapsing appendicitis has not the immedi- 
ate gravity of perforative appendicitis, it none the 
less creates in the long run a morbid condition which 



— 137 — 

renders life unendurable. These incessant attacks, 
grafted upon a permanent disorder of the intestines, 
transform the patient into a miserable invalid, inca- 
pable of any continuous work. At last these pa- 
tients, wearied and disgusted with opiates, revulsives 
and other medical means, which bring no effectual 
relief, will be impelled to seek of their own accord 
(as numerous recorded instances testify), benefit 
from a surgical treatment which promises a radical 
cure. 

21. Gravity of the Different Varieties of 
Appendicitis. 

We have indicated in connection with each form 
of appendicitis the respective gravity of the morbid 
accidents bearing relation to the progress, extension 
or localization of the appendicular or peritoneal les- 
ions. 

We have seen that there are mild forms, medium 
forms, and grave forms. What is the relative fre- 
quency of these different forms? It is difficult to 
say absolutely. If, however, we take account, not 
merely of the reported cases, which generally are 
cases of considerable if not of fatal severity, but 
of the impression given by daily observation, by 
hospital and city practice, we may boldly affirm that 
half of the cases belong to the mild forms, i. e., 
to parietal appendicitis, complicated or not with a 
certain degree of partial fibrinous peritonitis. This 



— 138 — 

figure may appear exaggerated to surgeons, who 
ordinarily see only the medium or grave forms; 
but it will seem to be an under-estimate to many 
physicians. It cannot unfortunately be based on 
any authentic statistics, for the report of these light 
cases is not ordinarily published. Only one kind of 
statistics will be of real worth, viz: such as shall 
group together all cases observed in a hospital in a 
certain number of years, with a full account of the 
mode of termination, of the complications and of the 
treatment employed. 

In this respect, the three following statistics may 
serve as data, in spite of the absence of details. 
Guttmann, summing up all the cases of perityphlitis 
treated at the Moabit Hospital since 1879, reckons 96, 
of which only five terminated by death. At the 
Friedrichshain Hospital, Furbringer in four years 
observed 120 cases of perityphlitis; there were 78 per 
cent, of recoveries, 12 per cent, of ameliorations and 
10 per cent, of deaths. 1 Fowler at the Middlesex 
Hospital observed in 10 years 99 cases of appendi- 
citis and perityphlitis; 84 got well, 15 died. 2 That 
is; in a total of 315 cases there were only 30 deaths. 
There remain 285 cases which got well. Grant that 
in these 285 recoveries, there were 80 or 100 cases 



1 Discussion at the Society of Internal Medicine, Berlin. Berl. Klin. 
Woch., May, 1891. 

2 Discussion at the Clinical Society of London. Brit. Med. Jour., 
March 7, 1891. 



— 139 — 

of suppurative perityphlitis which fortunately termi- 
nated either by spontaneous opening or by surgical 
evacuation of the pus, and we are making a large 
allowance for the benignity of suppurative peri- 
appendicular peritonitis. It is seen that there remain 
much more than half of the cases which can belong 
only to the mild forms, without perforation, or sup- 
puration. 

This much being said respecting the general 
gravity of appendicitis, we will class the forms we 
have described in the following order of decreasing 
gravity : 

1. Hyperacute perforative appendicitis; 

2. Sub-acute appendicitis with insidious course. 

3. Acute appendicitis with partial suppurative 
peritonitis. 

4. Chronic relapsing appendicitis. 

5. Parietal appendicitis with appendicular colic. 
A. It may be said that the hyperacute perforative 

form, with diffuse peritonitis, is surely fatal and in a 
short time. Some cases of recovery after early 
laparotomy do not authorize a modification of this 
general prognostication. 

Death is sometimes almost fulminant, 37 hours 
after the onset of the attack in a case of Earle. 1 
Fitz reports in his statistics eight cases of death in 
the first 48 hours. It is rare that the patient sur- 
vives the first week. 



Earle. Chicago Med. Jour, and Examiner, February, 1876. 



— 140 



The fatal termination must be attributed, in this 
form, either to the violence of the abdominal shock, 
or to the rapid septicaemia, or to the intensity of the 
diffuse inflammation of the peritoneum. 

B. I place in the second rank of gravity sub- 
acute appendicitis. This form is serious by reason 
of the nature and extent of the lesions, and of the 
deceptive insidiousness of the course of the affection. 
By causing the physician to hesitate on the diagnosis, 
by delaying the summoning of the surgeon, this 
insidiousness permits the suppuration without ob- 
stacle to advance in depth and extent, to infiltrate the 
neighboring muscles and tissues, and to provoke 
formidable and fatal complications. 

I have said that this form corresponds most often 
to perforation of the appendix in the retro-csecal 
tissue outside the peritoneum. I cannot admit the 
old notion which makes of cellular perityphlitis, of 
peri-caecal phlegmon, the most benign form of the 
perityphlites. Preferable would be a peritoneal 
perforation — on condition, of course, that the peri- 
tonitis be limited and that the purulent collection 
become encysted— for there is much more chance of 
early interference in time to evacuate the pus, than 
in a case of extra peritoneal perforation, the ravages 
and often fatal consequences of which one can 
neither foresee nor prevent. 

C. The third place I assign to perforative appen- 
dicitis with frank acute course, ending in eight to 



— 141 — 

fifteen days in the formation of an encysted purulent 
collection in the iliac fossa. It is this form whose 
treatment has profited especially by the exact knowl- 
edge of the cause and true seat of the lesions formerly 
attributed to inflammation of the caecum. The 
opportune intervention of the bistoury must more 
and more limit its gravity. It suffices to read the 
observations of appendicitis treated by an early 
operation to be convinced of this. Without doubt, 
surgery cannot pretend to effect a certain cure in all 
cases. But if failures are sometimes due to unex- 
pected complications, one can also often refer 
responsibility for failure to an operation too long 
deferred or incomplete. 

Besides, this acute form terminates favorably in a 
certain number of cases, without surgical help, 
spontaneous evacution of the pus taking place 
externally, either through the caecum or the rectum. 
Old observations of perityphlitis prove this. In 
what proportion is this mode of cure observed? It 
would be important to ascertain accurately and to 
compare this proportion with that which surgical 
interference gives. Unfortunately the statistics 
ordinarily lump together indiscriminately, cases 
most unlike, from hyperacute to simple appendicitis. 
We may, however, compare the statistics of Bull and 
Noyes, which seem to pertain only to suppurative 
perityphlitis. In 67 cases of perityphlitic abscess 
left to themselves, Bull, in 1875, noted but 35 



142 — 



recoveries, or 52 per cent. In 100 cases of peri- 
typhlitis treated surgically, Noyes, in 1882, ob- 
served 85 recoveries. 

As to spontaneous resorption of the purulent col- 
lection, we have no faith in such a result, although 
certain facts (Furbringer, Roux) seem to indicate the 
possibility of it; in any event the demonstration 
seems to us a matter of great difficulty. 

D. Chronic relapsing appendicitis is rather an in- 
firmity than a malady menacing to life. The pro- 
gressive thickening of the appendix or the protective 
adhesions which are formed around it, limit and al- 
most destroy the chances of a perforation. But the 
repetition of attacks, the intestinal troubles which 
persist in the intervals of the relapses, the cachectic 
state which finally takes possession of the patient, 
are facts which make the prognosis doubtful. 

JEJ. As to simple parietal appendicitis, it is a 
troublesome affection, because the possibility of a 
perforation necessarily haunts the mind of a physi- 
cian. But when limited to the walls of the appen- 
dix, and even when complicated with a certain degree 
of fibrinous peritonitis, it always gets well by medi- 
cal means. From the point of view of future wel- 
fare, one cannot help foreseeing the possibility of a 
recurrence, or the transformation of this first acute 
attack into a chronic relapsing appendicitis. 

This scale of gravity enables us to establish the 
proper prognosis of appendicitis under its different 



— 143 — 

aspects. The other elements of appreciation are com- 
mon to it and all other diseases: the age of the sub- 
ject, his degree of resistance, the existence of general 
or local diseases, previous or actual, etc. These con- 
siderations are always matters of less importance 
than the form of the affection itself. 

As regards age, the most that we can say is that 
in infancy the hyperacute perforative and the acute 
form with frank course are most commonly observed. 
In the child, appendicitis also quite often determines 
without perforation an extensive fibrinous peritonitis 
with violent symptoms, which easily gets well under 
medical treatment. In old age, on the contrary, 
when appendicitis is rare, perforation ordinarily takes 
place noiselessly and during the course of a disease 
that has pursued a very insidious course. Therefore, 
not only by reason of age, but also by reason of the 
appendicitis itself, the prognosis is very grave. This 
finds confirmation in the statistics of Einhorn, who 
demonstrates the frequency of fatal perityphlitis 
after 60 years of age. 

In regard to coexistent maladies, the frequency of 
tuberculosis, reservation being made of true tuber- 
culous typhlitis, is to be noted. It does not follow 
that every appendicitis supervening in a subject 
whose apices are suspected, is necessarily tubercu- 
losis; it may be absolutely independent of the pul- 
monary lesion and get well like an ordinary appen- 
dicitis. But it is also possible that the lesion of the 



— 144 — 



appendix serves as a focus of attraction to peritoneal 
tuberculosis; and on the other hand, by acting as a 
cause of depression and bad nutrition it may favor 
the extension of pulmonary localizations. 

Lastly, appendicites which supervene in convales- 
cence from acute diseases, typhoid fever, pneumonia, 
etc., are in general of an unfavorable prognosis. 
They ordinarily take the subacute form; the purulent 
inflammation takes place in an almost latent manner, 
and when there is no longer any doubt concerning 
the diagnosis of the affection it is generally too late 
to interfere. 



V. 

THE ERRORS OF DIAGNOSIS. 

The diagnosis of appendicitis does not generally 
present any difficulty. The ordinary clinical type is 
as easy to recognize as that of acute pneumonia. The 
suddenness of the onset, the pain in the right iliac 
fossa, the localized tumefaction of the caecal regions 
are as characteristic as the violent chill, the pain in 
the side and the rusty expectoration of common pneu- 
monia. Without doubt the deviations from the type 
may lead one into error, but this is the same in all 
diseases. 

The disputes raised by the surgeons are explained 
by the fact of their late summons to the bedside of 
the patient. At this moment, the phenomena of the 
onset are forgotten or misinterpreted, and what 
chiefly attracts attention is the swelling in the iliac 
fossa, with intermittent febrile state and gastrointes- 
tinal troubles. In the form with slow course, where 
the purulent collection develops insidiously, the diag- 
nosis is at times still more obscure. Moreover, the 
disputes of the surgeons generally pertain less to the 
diagnosis of appendicitis t han to the question of the 
presence or absence of a purulent collection in the 
abdomen. 

But in the acute forms with rapid progress, only 
those find any real difficulty who, holding to the 
10 



146 



notion of the old typhlitis insist on the presence of 
the elongated cylindrical tumor which to them rep- 
resents the inflamed caecum, or who, finding a painful 
resistance in the right iliac fossa, can see there only 
the caecum packed with faecal matters, and do not 
understand that in the immense majority of cases they 
have to do with a limited peritonitis consecutive to a 
perforation of the appendix. 

As for the hyperacute form, I maintain that the 
diagnosis is as simple as that of pneumothorax. 
Whenever in a child or adult habitually enjoying 
good health you notice the signs of acute peritonitis, 
you have reason to believe that there has been a per- 
foration of the appendix. If the signs of this peri- 
tonitis have been preceded by a violent attack of 
colic with a fixed painful point in the right iliac 
fossa, you are warranted in affirming perforative ap- 
pendicitis. This is really no new rule, for as early 
as 1853 Forget said that in presence of a primary 
peritonitis, without appreciable determining cause, 
one ought to consider perforation of the ileo-caecal 
appendix as very probable. 1 

It cannot but be, however, that grave mistakes of 
diagnosis have been made and will continue to be 
made. It is important to signalize the principal lia- 
bilities to mistake. 

The true interpretation of the facts may be falsi- 
fied: 



1 Forget. Peritonitis by perforation of the ileo-caecal appendix. 
(Gaz. Med. de Strasburg, 1853, p. 321.) 



— 147 — 

1. By the initial painful crisis; 

2. By the phenomena of intestinal paralysis and 
obstruction; 

3. By the general symptoms; 

4. By the tumor; 

This represents, so to speak, the differential diag- 
nosis of appendicitis. These causes of mistake being 
avoided, and the appendicitis recognized, it remains 
to determine one point which is a capital one for 
purposes of treatment, viz: if the appendicitis is per- 
forative or not. 

22. The Pain. 

This cause of mistake belongs only to the first two 
or three days of the disease. It will not be likely 
to give any trouble to the surgeon, who is seldom or 
never witness of that first phase which we call ap- 
pendicular, while interesting especially the physician 
who is called either during the course or on the very 
first day of the colic, and who ought to be able to 
decide as to the origin and nature of this attack. 

The description which we have given of appendic- 
ular colic is sufficient to indicate how for lack of at- 
tention it may be confounded : 

1. With an attack of hepatic colic; 

2. With an attack of nephritic colic; 

3. With an indigestion; 

4. With a painful crisis of membraneous entero- 
colitis. 



— 148 



a. Hepatic colic. — It is surely easier to indicate 
on paper the differential characters of these two 
kinds of colic, hepatic and appendicular, than to 
recognize these differences at the bed of the patient. 
Paroxysmal pains, vomitings, syncopal anguish, 
pinched features are symptoms which are the same 
in both cases. In hepatic colic the pains are rather 
stomachal, under the form of epigastric constriction, 
cramps of the stomach; the vomitings are more fre- 
quent, more obstinate. In appendicular colic the 
pain is rather intestinal, sub-umbilical or peri-umbi- 
lical; there are generally but one or two vomitings of 
food. The hepatic pains radiate upwards towards 
the shoulder, backwards towards the point of the 
scapula; the sensibility is extreme under the lower 
ribs, and the fixed painful point is just over the gall- 
bladder. In the appendicular pain, these higher 
irradiations are wanting, the painful paroxysms seem 
to converge towards the umbilicus and follow the 
course of the large intestine. The fixed point is in 
the right iliac fossa. 

But on the one hand, if you are present during the 
attack, it is not easy, in the midst of the sufferings in 
which the patient is writhing, to get him to indicate 
these shades with precision; on the other hand, when 
the attack is over, nothing is more difficult than to 
give an exact description of a painful sensation, and- 
it is not at all easy to obtain from the patient the 
detail of differences which perhaps are oftener more 
theoretical than real. 






— 149 — 

Hence, then, if it happens to be a first attack of 
the kind, and if there is nothing present but the ap- 
pendicular colic without consecutive appendicitis, 
one will remain almost necessarily in doubt. If, on 
the contrary, the attack has been preceded by other 
similar crises, the diagnosis will be arrived at by 
eliciting the phenomena which have followed some 
one of the previous attacks: icteric tint, gastric 
troubles, in the case of biliary lithiasis — persistence 
during several days of the right iliac pain, in the 
case of appendicular colic. It is rare, indeed, that 
the appendicular attacks are repeated without being 
followed, at one time or another, by a certain degree 
of appendicitis. 

When the appendicular colic is only the first phase 
of acute inflammation of the appendix, the mistake 
will not be continued, for the iliac pain, the deter- 
mination of Mac Burney's point, the rigidity of the 
abdominal muscles over the caecum must, in 24 hours, 
lead to a decision as to the veritable nature of the 
accidents. 

It is, however, necessary to know that calculous 
cholecystitis, while having its maximum painful point 
under the costal border, may provoke irradiations all 
along the ascending colon, and, according to Potain, 
even have an extension to the right iliac fossa. 
These cases are, however, very rare, and, as Maurin 
observes, calculous cholecystitis is an affection which 
is chiefly observed in old age, when appendicitis, on 
the other hand, becomes exceptional. 



— 150 — 



6. Nephritic colic. — Mistake is still easier in 
nephritic colic. Like appendicular colic, its pain rad- 
iates downward, towards the groins and testicles, 
and often gives rise to tenesmus and to desires to go 
to stool; like nephritic colic, appendicular colic may 
cause retraction of the right testicle, frequent desires 
to urinate, a certain degree of oliguria with painful 
micturition. I know of a case where the mistake 
was committed and maintained with strange obsti- 
nacy by a group of distinguished physicians and sur- 
geons; the patient succumbed the fourth day; the 
autopsy revealed a perforated appendix with sup- 
purative peritonitis. But just as in hepatic colic, 
it is not likely, unless under very extraordinary cir- 
cumstances, that the mistake will be continued be- 
yond 24 hours, when the appendicitis follows the 
attack of colic. The localization of the signs in the 
right iliac fossa should not allow an attentive phy- 
sician to be deceived longer about the true diagnosis. 

c. Indigestion. — If the initial painful crisis is of 
great intensity, the presumption will generally be in 
favor of either nephritic or hepatic colic. If the ab- 
dominal pain is, on the contrary, of little violence 
and resembles a simple intestinal colic, it will be like- 
ly to be confounded with indigestion. It is most 
often after a copious meal or after eating some indi- 
gestible food that appendicitis suddenly manifests 
itself, and the first effect of the intestinal pain is to 
make the patient vomit up the food contained in the 



— 151 — 

stomach. In fact, it is by an indigestion that the 
morbid scene begins; the delicate point is to distin- 
guish from a simple indigestion this indigestion which 
is symptomatic of an affection that is sometimes 
fatal in 48 hours. 

I do not see, especially when the patient is a 
child incapable of locating the seat of his sensations, 
the means of avoiding mistake in the initial period. 
But the phenomena of a simple indigestion are ordinar- 
ily not prolonged beyond several hours. Seeing the 
accidents persist, the pain localize itself on pressure, 
the belly retracted or tympanitic, the pinched fea- 
tures, one will be warranted in suspecting appendici- 
tis. It will not do to allow oneself to be deceived 
by the period of apparent calm which sometimes fol- 
lows the first crisis of appendicitis, and which pre- 
cedes perforation. In too soon forming a favorable 
conclusion from this period of lull and venturing a 
prognosis of little gravity, one runs the risk of being 
cruelly undeceived, in finding 24 hours afterwards 
the patient suffering all the signs of a generalized 
peritonitis. 

d. Muco-membranous enter o-colitis. — Glairy or 
membranous colitis often gives rise to crises of colic 
which resemble appendicular colic. Here mistake 
may be made in two ways: either by supposing an ap- 
pendicitis to be present which does not exist, or by 
diagnosticating a mucous colitis when the real 
trouble is appendicitis with consecutive intestinal 



— 152 — 



atony. The confusion is the easier, because the sud- 
denness of the onset, as well as the exciting causes 
(cold, fatigue, errors in diet, constipation), are the 
same in both cases. Besides the general course of 
colitis with its intermittent crises is very similar to 
that of chronic appendicitis with its successive re- 
lapses. Lastly, it should be remembered that glairy 
colitis does not exclude appendicitis, and that often 
it exists first and favors the production of appendi- 
citis; the muscular and secretory atony of the large 
intestine being in my opinion the most common cause 
of the formation of the stercoral balls which are 
deposited in the caecum. 

In these cases it is the attentive exploration of the 
abdomen, and the exact determination of the seat of 
the pain which will decide the question of diagnosis. 
Mac Burney's painful point, accompanied by a 
muscular contracture localized in the right side of 
the abdomen, suddenly succeeding a crisis of colicky 
pains more or less general, belongs only to appendi- 
citis. In colitis the pains are and remain diffuse, and 
if they tend to become localized in a point painful to 
pressure, it is generally on the left side, over the 
descending colon and sigmoid flexure, that this fixed 
point is noted. 

The general sensibility of the abdomen, the 
phenomena of peritonism, the glairy stools, the pro- 
pagation of the irritation to the bladder, a fever 
more or less marked, may be observed in both affec- 
tions. 



— 153 — 

The tenesmus with sanguinolent stools or stools 
containing membranous debris, the temporary but 
complete lull after this expulsion of membranes or 
after a dose of castor oil which brings away a large 
quantity of hardened faeces, are rather symptoms of 
colitis than appendicitis. 

e. Abnormal seat of the fixed pain. — The rule is 
that the appendix is found in the right iliac fossa, 
and consequently that the fixed and limited pain 
complained of by the patient and provoked by the 
pressure of the finger, occupies this region. But we 
know that the appendix, normally or by reason of 
previous adhesions, may undergo divers deviations, 
sometimes to the left, sometimes backwards, some- 
times inwardly against the psoas muscle. 

In these conditions the deviation of the painful 
point may give rise to mistakes. Routier has re- 
ported a case where a hyperacute perforative appen- 
dicitis began by a sudden pain in the left hypochon- 
drium. Peritonitis by perforation was diagnosticated; 
but the idea of appendicitis was rejected by reason 
of the left-sided seat of the pain. Nevertheless, the 
autopsy showed the appendix perforated at the 
point, with a faecal ball imprisoned in its middle. 1 
Frankel, in the discussion raised by Sonnenburg at 
the Society of Internal Medicine of Berlin, says that 
he has observed a case where all the phenomena of 



Semaine Medicale, August, 



154 



appendicitis were produced in the left iliac fossa, the 
right being absolutely normal. 

On the other hand, in case of posterior deviation, 
the pain may be referred to the right lumbar region; 
one would then be inclined to attribute the symp- 
toms to a lumbo-abdominal neuralgia or to a peri- 
nephritis. 

Lastly, Gibney has pointed out the possibility, 
especially in children, of confounding a perityphlitis 
with a coxalgia. He reports a case where the first 
symptom complained of was a pain in the right hip. 
In five other cases the attitude of the patient was 
that of the coxalgic: thigh bent on the pelvis, pelvis 
inclined to the right, lordosis very marked. In these 
cases Gibney noted a tumor in the right iliac fossa 
which twice only suppurated. Although Gibney 
admits the existence of a primary perityphlitis, he 
fully believes that he had to do, in the cases of which 
he writes, with appendicitis with periappendicular 
inflammation; the appendix being deviated inwardly 
and into direct relation with the psoas and iliacus 
whose contracture produced the painful flexure of 
the thigh. 1 



1 Gibney. Perityphlitis in children, illustrating points in the dif- 
ferential diagnosis of hip diseases. Amer. Jour, of Med. Sci., January, 
1881, p. 119. 



— 155 — 

23. Phenomena of Internal Strangulation. 

The symptoms of intestiDal paresis, which in the 
mild forms of appendicitis manifest themselves by a 
more or less obstinate constipation, attain sometimes 
such a degree of intensity when the perforation 
takes place into a peritoneum perfectly healthy, that 
the aspect of the patient resembles that of an 
individual affected with internal strangulation. 

The violence of the abdominal shock immediately 
produces collapse, with general coldness, cyanosis, 
arrest of the urinary secretion and peristaltic intes- 
tinal movements. The paralysis of the intestine is 
so complete that neither fseces nor flatus is passed, 
and fsecaloid vomitings are observed. The belly, 
more or less tympanitic, is hard and tense as a drum. 

In these conditions which are met only in hyper- 
acute appendicitis with general peritonitis, the mis- 
take has often been made and laparotomy performed 
for an internal strangulation. 

Ransohoff published 12 cases of appendicitis where 
the symptoms were those of strangulation. Hartley 
has seen two cases where an operation for strangula- 
tion was performed, the symptoms of obstruction 
were found due to a gangrenous appendix. ' 

Peyrot has reported similar cases. 2 

Moreover this confusion with internal strangula- 



1 (N. Y. Med. Rec, Aug. 16, 1890.) 
• These eT agreg, Paris, 1880. 



— 156 — 

tion is not special to appendicular peritonitis. Every 
peritonitis by perforation, whatever may be the ori- 
gin of the perforation, may produce it, and the simi- 
larity of the symptoms is such as to deceive the most 
expert clinicians, just as in the cases of Henrot's 
patient where the abdominal lesions was supposed to 
be internal strangulation, and the autopsy showed 
perforation of the gall-bladder with general periton- 
itis. 

The mistake is of less consequence to-day since 
the indication for laparotomy is the same in both 
cases. 

The principal differential characteristic is the state 
of the temperature; so say various writers. "The 
temperature," says Peyrot, " always rises in periton- 
itis; it often attains 39° C. and even 40°. In stran- 
gulation, on the contrary, the temperature falls or at 
least does not exceed the normal, and if hyperthermia 
supervenes, it is because there is a complication of 
peritonitis." This is true in a general way; but this 
character is absolutely illusory in a case where, by 
reason of the intensity of the abdominal shock, the 
peritonitis by perforation resembles strangulation 
most closely. In these cases, not only there is no 
rise of temperature to 39° or 40° C, but the temper- 
ature remains normal or even sub-normal, as in the 
case which I have reported of a young woman af- 
fected with perforating ulcer of the stomach. In my 
opinion the true differential sign is furnished by an 






— 157 — 

examination of the abdomen. In strangulation there 
is always very pronounced meteorism. In the cases 
of hyperacute peritonitis by perforation where the 
symptoms of strangulation are most marked, the belly 
is not distended; it is, on the contrary, rather exca- 
vated, hard, tense, being rendered rigid by the con- 
tracture of the abdominal muscles. 

There exist, however, cases in which the study of 
the temperature has great value and becomes an ex- 
cellent means of diagnosis; it is when the symptoms 
of obstruction coincide with an appendicitis which 
has given rise, not to a general peritonitis, but to 
a localized suppurative peritonitis or abscess. In 
these conditions, whether the obstruction be due to a 
reflex paresis of the large intestine, or to the com- 
pression brought to bear on the colon by the purulent 
collection, the existence of a remittent fever with 
evening exacebations, the attentive observation of 
course of the disease, its mode of onset, the previous 
history etc., should put the physicians on the right 
track and indicate the cause of the obstruction. 

One of the varieties of internal strangulation, ileo- 
cecal invagination, might in particular, according to 
Reclus, be confounded with appendicitis. It gives 
rise, in fact, to a severe pain followed by a tumefac- 
tion which often occupies the right loin, to digestive 
and peritoneal troubles, to symptoms of occlusion 
which remind one of perforation of the appendix. 
Reclus gives as a differential character of the invagi- 



— 158 — 

nation, the less sharp and more localized pain, the 
rare and less early fever, the later and more obstinate 
vomitings, the existence sometimes of bloody stools, 
finally the fact that the seat of the tumefaction is not 
absolutely the same. 1 These characteristics appear 
to me very vague. 

It were better to say that invagination is a rarity 
and to recognize that it is well nigh impossible to 
diagnosticate it with certainty. 



24. The General Symptoms. 

The febrile symptoms, in the acute forms, the 
cachectic aspect, in the subacute and chronic forms, 
may lead into error, in certain cases, and cause the 
physician to suspect sometimes a typhoid fever, some- 
times a tuberculous peritonitis. 

a. Febrile state. — The fever is rarely very high in 
appendicitis. It sometimes happens, however, that it 
rises in the first days to 39 and even 40° C. for a short 
time. Coupled with the gastro-intestinal troubles, 
with pain in the right iliac fossa, with the prostrated 
appearance of the patient, it has sometimes caused 
suspicion of an onset of typhoid fever. But one 
must needs be remarkably stupid to long adhere to 
such a diagnosis. 

Even when high at the onset, the fever does not 
last, and falls at the end of two or three days; in any 



Reclus, Des Appendicitie, Rev. de Chirurgie, Oct. 1891. 



— 159 — 

case, the curve of temperature is absolutely irregu- 
lar. The iliac pain in typhoid fever never shows 
the intensity of appendicular pain. Finally vomit- 
ing, as an initial symptom of typhoid fever, is rare. 

b. Cachectic aspect. — Although subacute appendici- 
tis may give occasion for mistake in diagnosis, when 
the suppuration takes place insidiously and noiselessly 
with accompaniment of remittent fever with even- 
ing exacerbations, it is especially chronic relapsing 
appendicitis which is liable to misinterpretation, being 
mistaken for tuberculous peritonitis. I know of a 
patient who, having already had two attacks of acute 
appendicitis, presented during the third such symp- 
toms of intestinal cachexia with extreme emaciation, 
slight hectic fever, etc., that the physician in charge 
diagnosticated an entero-peritoneal tuberculosis; and 
such was his confidence in this diagnosis that he even 
believed himself to find at one time dry cracklings at 
the apex of one of the lungs. The patient finally 
got well at the end of five or six months, and for 
twelve years has never had any symptom pointing to 
the existence of pulmonary or peritoneal tuberculosis. 

Relapsing appendicitis, especially when it exists in 
relation with the persistence in the vicinity of the 
appendix of a small pus-pocket, source of putrid in- 
fection, may give rise to a symptomatology which 
hardly differs from that of chronic tuberculous peri- 
tonitis. There is the same general aspect, with ema- 
ciation, earthy complexion, abdominal facies; the 



160 



same febrile accessions with evening intermittences, 
the same alternations of diarrhoea and constipation 
with distention of the abdomen, the same acute 
attacks with nausea and vomitings. A minute ex- 
amination, an attentive interrogation, a prolonged 
observation of the subject, are necessary to arrive at 
a conclusion; and sometimes it is impossible to do this 
with certainty. 

The fact is that the two things, tuberculosis and 
appendicitis, may co-exist, and such co-existence is 
not absolutely rare. From this point of view, it is 
necessary to distinguish three categories of cases: 

1. The appendicitis is produced by the ordinary 
mechanism, traumatic or stercoral appendicitis, in a 
tuberculous subject, at any period whatever of the 
tuberculosis, without there being, properly speaking, 
any tuberculous lesion of the intestine. 

2. The appendicitis is due to the propagation of a 
tuberculous entero-colitis to the appendicular mucosa, 
with specific ulceration of this mucosa, and finally 
perforation at the level of the ulceration. These 
cases are exceptional, and up to this time, very few 
observations of this kind have been published. 

3. The appendix has no longer a causal relation; 
the lesions are situated in the caecum itself; it is really 
a tuberculous typhlitis. The ulcerous inflammation 
of the mucosa has for its consequence a thickening 
of the csecal walls with tuberculous peritonitis limited 
to the region, the whole forming a tumor more or less 






— 161 — 

clearly defined in the right iliac fossa. This tumor, 
joined with the duration of the disease and the 
cachectic condition of the subject, suggests cancer of 
the caecum rather than appendicitis. Billroth has re- 
ported to the Imperial Society of Medicine of Vienna 
a case of this kind, which gave rise to accidents of 
obstruction; the diagnosis of cancer was made. 1 In 
one of Pilliet's cases* the autopsy showed the caecum 
reduced to a sort of ampulla, of the size of a small 
orange, with thick and rigid walls, interposed 
between the two intestines. There was no longer any 
trace of the ileo-caecal valve, and the appendix was 
represented only by a very small lateral cavity like 
the finger of a glove. Around the caecum were a 
great number of caseous glands of the size of a bean 
or of a hazel-nut. 

What the communication of Pilliet and Hartmann 
makes particularly prominent, is the special aspect 
of this form of tuberculous typhlitis. The lesions 
do not resemble ordinary bacillary ulcerations. There 
is a veritable granular proliferation, with hypertro- 
phy of the mucosa, which conceals in part the ulcer- 
ated surface; it is a sort of villous papillomatous 
state, such as is found in certain cases of laryngeal 
phthisis, and which, to the naked eye, suggests the 
idea of cancer. But the microscope shows the histo- 
logical lesions of tuberculosis. 



1 Billroth, Imp. Soc. of Vienna, Feb. 27, 1891. 

2 Pilliet and Hartmann. Note on a variety of tuberculous typhlitis 
resembling cancer of the region. Soc. anat., July and Nov., 1891. 

11 



— 162 — 

It must not be thought that all tuberculous typhli- 
tes answer to this type; in this case we are evidently 
concerned with a chronic process of very slow evolu- 
tion. In other cases, of more rapid progress, the 
ulceration tends to perforate the caecal walls, and 
there results from it a real suppurative perityphlitis, 
as in the case of the patient observed by M. Duguet. 1 
In such a case if the tuberculosis is localized in the 
caecum, if no signs of pulmonary phthisis exists, it is 
very difficult to avoid mistakes, and the diagnosis 
will almost necessarily fail to include the specific na- 
ture of the pericecal suppuration. 

We must compare with tuberculous appendicitis 
the still more rare cases of actinomycosic appendici- 
tis, like that which Ransom recently communicated 
to the Medical and Surgical Society of London. The 
diagnosis can be made only after opening the abscess 
and by detecting in the pus the characteristic 
granula formed by the colonies of actinomycetes. 2 

25. The Tumor. 



I doubt whether in acute appendicitis with limited 
peritonitis there can be any mistake about the tumor, 
if the disease has been followed from the onset. It is 
only in the case of a female that a mistake seems 



1 Duguet. Phlegmonous typhlitis in a case of tuberculous enteritis. 
Gaz. Med. de Paris, 1870. 

2 Ransom. Royal Med. and Surg. Soc, of London, April 16, 1891. 



— 163 — 

possible, or in the event of the physician being called 
at a late date, when the disease is fully developed, 
and there are insufficient, or misleading commemora- 
tive data. 

It is chiefly in sub-acute appendicitis that the phy- 
sician can be led astray by misunderstanding the 
slow, insidious and irregular course of the affection, 
on the one hand, and on the other, the abnormal 
localization of the purulent collection due to some 
one of the deviations of the appendix. 

a. I am not going to repeat what I have said re- 
specting caecal or appendicular tuberculosis. But 
cancer of the ileo-caecal valve sometimes produces 
symptoms which resemble sub-acute appendicitis, 
especially when it is complicated with gradual per- 
foration of the intestinal walls, and with formation 
around the caecum of purulent foci with fsecaloid 
pus. At an advanced period of cancer, the cachexia 
and cancerous anaemia, ordinarily very pronounced in 
malignant tumors of the ileo-caecal valve, will enable 
one to recognize or at least to suspect the organic 
lesion back of the purulent complication. 1 But if 
this complication supervenes in the first phases of 
the cancerous affection, the mistake will be with diffi- 
culty avoided. 

The converse, however, is also possible. A sub- 



1 Wacquet. Cancer of the caecum with narrowing of the colon. 
Abscess of the iliac fossa opening into the gluteal region. Soc. Anat., 
1846, p. 155. 



— 164 — 



acute appendicitis with adhesive periappendicular 
peritonitis without suppuration, supervening in a 
man who is past 40, may give rise to symptoms of 
emaciation, asthenia and general anaemia which, 
taken in connection with the finding of a more or 
less limited swelling in the right iliac fossa, and with 
the infrequency of appendicitis beyond 40 or 45 
years, will almost necessarily make the diagnosis lean 
in favor of a malignant tumor in the ileo-caecal 
region. 

It is impossible to give precise rules to settle the 
question in such cases. As in tuberculous appendici- 
tis it is chiefly a matter of attentive observation, 
minute and prolonged, and also of clinical acuteness 
and skill. 

The mistakes due to abnormal location of the 
abscess are of two kinds: the one kind, common to 
both sexes, pertains to the not uncommon vertical 
deviation of the appendix behind the caecum; the 
other, peculiar to woman, depends on the direction of 
the appendix downwards and inwards towards the 
pelvis. 

b. The upward and backward deviation has for con- 
sequence the formation of a purulent collection in 
the lumbar region. Hence possible confusion with a 
perinephritic abscess. There are given as differential 
marks: the tendency of the peri-renal abscess to pro- 
ject backwards, the oedema of the dorsal region and 
the absence of pus or albumen in the urine. This is 



— 165 — 

a diagnosis of the study rather than of the clinic. 
In many cases of perinephritis, there exists no modi- 
fication of the urine. On the other hand, a retro- 
cecal abscess may cause oedema of the dorsal region 
and point in the back, and when left to itself, it 
sometimes opens into the lumbar region and leaves 
there a permanent fistula. 1 The truth is that here 
again only an exact interpretation of the commemor- 
atives can help one to diagnosticate the origin of the 
pus. But I am much inclined to believe that a good 
many abscesses of the dorso-lumbar region are diag- 
nosticated and opened as perinephritic abscesses, 
without even a thought that they may possibly be of 
appendicular origin. 

When the appendix rises very high behind the 
large intestine, or when the inflammation is propa- 
gated very rapidly towards the infra-hepatic region, 
a less frequent consequence of this posterior devia- 
tion is to divert the attention from the appendix and 
lead the physician to believe that there is an affection 
of the liver or of the gall bladder. The following 
observation of W. W. Keen is instructive in this 
particular: 

A young woman aged 30 years was suddenly taken 
with violent pains below the right costal margin. 
The next or the third dav one of her children acci- 



1 Mending, Lumbar fistula communicating with the caecum, coming 
on after inflammation and suppuration of the neighboring parts; recov- 
ery. Arch, gen denied., 18U2. 



166 



dentally struck her in the same region, producing a 
sharp pain. Five days afterward the pains became 
extremely severe and the patient fell into such a state 
of collapse that her physician thought she was going 
to die. The temperature was below 36° C. A pow- 
erful stimulant revived her, but the pain continued. 
Another collapse took place the eighth day, with 
coldness of the extremities; it was then that Dr. 
Keen was called in consultation. 

The thigh was flexed, the right side of the abdo- 
men extremely sensitive, with marked tension of the 
muscles; the least contact produced a sharp pain. 
On the left side a moderate pressure was tolerated. 
The pain was located exactly below the inferior bor- 
der of the liver, diminishing progressively towards 
the right iliac fossa. Nothing was noted on the part 
of the uterus and its annexes. An exploratory lapar- 
otomy was decided upon for the next day, as the 
diagnosis was hesitating between an appendicitis and 
an undetermined affection of the liver or gall- 
bladder. 

On opening the abdomen, the left border of the 
liver was seen attached to the colon by recent ad- 
hesions, and the parietal peritoneum was strongly 
injected at this point. The gall-bladder was normal, 
also the kidney, no trace of abscess could be dis- 
covered, nor any cause of inflammation. The right 
iliac region and the caecum presented no lesion, but 
the appendix could not be found. The intestines 



— 107 — 

were normal as well as the uterus and the ovary. 
There was a great accumulation of serosity in the 
right side. The abdomen was washed with warm 
water and closed without the cause of the morbid 
accidents being found. The patient died four days 
after the operation. 

The autopsy revealed a perforative appendicitis. 
The appendix, of the length of three inches, ascended 
directly behind the caecum and colon, being agglutina- 
ted to the wall of the large intestine, between the 
two folds of the meso-colon. Its extremity was per- 
forated, and communicating with a little abcess con- 
taining hardly a spoonful of pus mixed with some 
faecal matters. 1 

c. The downward and inward deviation of the 
appendix explains the difficulties of diagnosis of ap- 
pendicitis in women. Descending towards the pelvis, 
the appendix is placed in direct relation either with 
the tubes, and especially the right, or with the uterus 
or the vagina. The encysted peritonitis which results 
from the perforation of the appendix in this position, 
is then confounded with the consequences of the 
lesions of the womb or its annexes. If we add to 
this that appendicitis is relatively rare in the female; 
if we reflect on the natural tendency to attribute to 
some alteration of the genital organs all the painful 
or inflammatory phenomena from which women suffer 
in the region of the pelvis, it will be seen that the 



W. W. Keen, Philadelphia Medical Society, Sept. 28, 1891. 



168 



mistake is quite easily made, and it may be that 
appendicitis appears to be so rare in the female only 
because it is not diagnosticated. 

A woman entered the service of Richelot 1 with all 
the signs of salpingitis, or at least of a lesion of the 
annexes, sensibility to the touch, tumefaction giving 
to the vaginal touch the sensation of a dilated and 
inflamed tube, severe pains, difficulty in walking. 
Laparotomy was practiced, and the appendix found 
increased in size and adherent to the ovary and right 
tube. The appendix was isolated and resected; it 
contained a little parietal abscess but no foreign body. 
The left ovary was cystic. The intimate fusion in 
certain cases of the appendix with the tubo-ovarian 
annexes is not likely to facilitate the distinction 
between the lesions of the two organs. 

It is with pyosalpinx that the confusion is without 
doubt oftenest made. But the two observations of 
Burke prove that hematocele may also be one cause 
of mistake. One of his cases was a hematocele, 
ending fatally in 48 hours; the diagnosis of perforative 
appendicitis had been made. In the second a hema- 
tocele had been diagnosticated and the autopsy 
showed a perforated appendix with gravid uterus. 
The coincidence of pregnancy is not likely to facili- 
tate diagnosis. Oppenheimer observed a woman who, 



l Bull. Soc chir. Oct. 15, 1890. 



— 169 — 

at the seventh month of pregnancy, was taken with 
bilious vomitings, irregular fever, swelling of the 
spleen, without very marked pain in the belly or ap- 
preciable tumor in the right iliac fossa. Three days 
after she gave birth to a child who soon died. The 
fever continued; then at the end of several days there 
appeared in the right loin a voluminous tumor, large 
as the head of a child; it was thought to be a renal 
tumor. The patient succumbed rapidly. At the 
autopsy a perforative stercoral appendicitis was found ; 
the appendix was situated behind the caecum, and the 
perforation was in the retro-ca?cal tissue; the pus had 
burrowed along the kidney and between the two 
folds of the mesentery to the retro-peritoneal space; 
there were metastatic abscesses in the liver and 
spleen. 

In a patient of Welch's an extra uterine tubal 
pregnancy has been diagnosticated. Three weeks 
after her entrance into the hospital, the sac burst into 
the peritoneum and there was a profuse haemorrhage. 
The bloody liquid, removed from the peritoneal cavity 
by aspiration, gave a pure culture of the bacterium 
coli commune. Welch concluded that there must have 
been an intestinal perforation. There was no other 
sign pointing to appendicitis. Laparotomy was 
attempted, but the patient died in the operation. At 
the autopsy, appendicitis with general peritonitis was 
found. There was a right-sided tubular pregnancy 



— 170 — 

with rupture of the sac, to which the perforated ap- 
pendix was adherent. 1 

26. Diagnosis of the Forms of Appendicitis. 

The causes of mistake being avoided and appendi- 
citis recognized, an important point still remains to 
be diagnosticated, i. e., the form of > the appendicular 
inflammation; is it parietal or peritoneal, fibrinous 
or purulent, simple or perforative? We have seen 
that the prognosis depends almost entirely on a cor- 
rect decision on these matters. It is the same with 
the treatment. The problem, in short, is summed up 
in these two questions: 

Can it be said that an appendicitis will be perfora- 
tive? 

Can one recognize whether an appendicitis is per- 
forative ? 

A. The first question is encountered at the very on- 
set of the affection. It must be acknowledged that it 
is well-nigh insoluble. The only form of appendicitis 
in which one may foresee from the beginning the 
course of the disease, is chronic relapsing appendi- 



1 Oppenheimer. Discussion at the Society of Internal Medicine of 
Berlin. Berlin Klin. Woch., May, 1891.— See also a fatal case of perfor- 
ated appendicitis with diffuse peritonitis in a woman in the third month 
of pregnancy. (N. Y. Med. Record, Jan. 23, 1892.) 

Welch. N. Y. Med. Record, Dec. 1891.— See also the case reported 
by Harrington (Boston Medical and Surgical Journal, Dec. 10, 1891), 
where the deviation caused the physician to diagnosticate a tumor of 
the ovary. 



— 171 — 

citis. Even here it must be added that it is only at 
the third or fourth recurrence that one can decide 
with any confidence, the perforation being less and 
less probable the more frequently the attacks are re- 
peated. One must also remember that perforation 
may take place during the first or second recurrence, 
and only give rise to a small encysted abscess, and 
that later recrudescences are due to inflammatory 
outbreaks in the vicinity of this abscess. 

But in the other varieties of appendicitis, on what 
data shall we rely to predict the mode of termination 
of the attack? The perforation is never immediate, 
we have already sufficiently insisted on this point. 
It is always preceded by what we have called the 
appendicular phase, during which the inflammatory 
process goes on, which may or may not end in the 
rupture of the appendix. This phase lasts 24, 48 or 
72 hours. During all this time it is impossible to 
reach a decision. Neither the suddenness of the 
onset, nor the character or intensity of the pains, nor 
the presence or absence of fever, permit a conclusion 
in one way or the other. For the most acute 
symptoms may yield to leeches, to a hypodermic 
injection of morphine, without the inflammation 
passing beyond the walls of the appendix; and, on 
the other hand, the appendicular phase may be very 
quiet, with little pain, so that the signs of peritonitis 
by perforation seem the first indication of serious 
disorder. 



172 



However, this necessary reservation has no prac- 
tical importance, apart from a few exceptional cases, 
like those published by certain American surgeons. 
In general, the patient does not consult the physician 
at the onset of an appendicitis; he believes himself 
to be suffering from simple colic or indigestion; 
ordinarily he takes a purgative on his own responsi- 
bility, and it is only at the end of two or three days 
that, seeing the pain persist or increase, he decides 
to summon the physician. 

B. In fact the true difficulty is in knowing whether 
the perforation exists or not. Now it may be said 
that by the third or fourth day, in the immense 
majority of cases, this difficulty hardly exists. 

At this moment one either observes or does not 
observe the signs of an acute peritonitis, partial or 
general. 

If they are not observed, i. e., if there is neither 
extreme pain over the abdomen on pressure, nor 
tympanism, nor repeated vomitings, nor hiccough, 
nor pinched features, nor high fever, there are at 
least five chances out of ten that the appendicitis is 
and will remain simply parietal. 

There are, however, cases in which, although the 
signs of acute peritonitis are wanting, the perfora- 
tion none the less takes place, either into a very 
restricted space, walled in by adhesions, or into the 
extra peritoneal cellular tissue. 

Here it is only the attentive exploration of the iliac 



— 173 — 

fossa which will enable one to decide, and often the 
retraction and tension of the abdominal muscles ren- 
der this exploration very difficult. In general, how- 
ever, a more or less well-defined swelling is perceived, 
either deep down in the iliac fossa, or higher up and 
external, above the antero-superior spine of the ilium. 
This last location, in connection with the absence of 
peritoneal phenomena and the obscurity of the gene- 
ral or functional symptoms, should lead one to sus- 
pect a perforation into the retro-csecal cellular tissue. 
One must take care in this case to avoid the tendency, 
perpetuated by the old notion of stercoral typhlitis, 
to attribute this elongated swelling to a simple faecal 
engorgement of the caecum. 

If the signs of an acute peritonitis, general or 
partial, exist, there is hardly room for hesitation. 
Diffuse peritonitis is generally connected with the 
hyperacute perforative form. One sometimes, it is 
true, observes the symptoms of a peritonitis, at first 
general, becoming localized at the end of several days 
in the right iliac fossa; but that may be considered as 
exceptional. 

If the peritonitis is partial and localized in the 
right loin, a new question presents itself: is the in- 
flammation fibrinous or purulent? Is there or is there 
not a collection of pus? 

I believe that it is almost impossible to decide with 
certainty during the first week. Without doubt, 
when the local signs are very marked, when the gen- 



174 



eral condition is very grave, when the fever rises to 
39 and 40° C. and persists at this height, there is rea- 
son to believe that perforation has taken place with 
the usual purulence of the peritoneal effusion. But 
even these symptoms may be almost as well marked 
in some cases of pseudo-peritonitis or of local peri- 
tonism, so that absolute certainty is not always war- 
rantable. Simple fibrinous peritonitis may at least 
for several days give rise to symptoms apparently as 
dangerous as a peritonitis purulent from the first. 

All this would not matter much if we believed in 
the desirableness of an early operation in all cases; 
supposing that the diagnosis is not quite clear, the 
surgeon's scalpel will remove all the mystery. If 
however we believe in an operation only for the sup- 
purative cases, we shall feel the necessity of being 
sure as to the presence of pus before we consent to a 
laparotomy. 

It is impossible for us now to be satisfied with the 
signs which led the old surgeons to diagnosticate sup- 
puration; local pain, sharp and throbbing, fluctuating 
tumor, attacks of intermittent fever. These signs 
indicate rather incipient infection of the organism 
than the processes of suppuration properly so called. 
To wait for these, is to leave the patient exposed to 
all the dangers which have from of old menaced the 
victims of perityphlitis, and which have brought an 
early operation so much into demand. It is certain 
that pus sometimes exists in perforative appendicitis 



— 175 — 

from the first forty-eight hours. It is absurd then to 
wait till the third or fourth week when the presence 
of a pus collection is no longer doubtful to the judg- 
ment of the most inexperienced physician; we ought 
the rather to assure ourselves as early as possible of 
the presence of pus that we may give it a free vent 
externally, in accordance with the old precept: ubi 
pus, ibi evacna. 

Some American surgeons have recommended the 
exploratory puncture; Furbringer, Renvers, in Ger- 
many, also declare themselves advocates of this as a 
means of diagnosis, and consider it without danger. 
Treves, on the contrary, strongly opposes its employ- 
ment, and Roux of Lausanne also condemns it, "be- 
cause," he says, "this puncture is sometimes danger- 
ous, very often loithout result, and always useless." 

I am absolutely of the opinion of Treves and 
Roux. I do not understand how the exploratory 
puncture can seem harmless to Furbringer. Let one 
consider that it is a matter of plunging a needle, 
sometimes three or four times, to the depth of three 
or four inches into the abdominal cavity, of pushing 
it blindly around in different directions in a region 
where the iliac blood-vessels are situated, as well as 
the ureter, the caecum, and the intestinal coils more 
or less displaced and inflamed. The operation of 
aspirating an intestine which is only in a tympanitic 
state (as in the meteorism of typhoid fever-paralysis) 
is not without danger; how then can we suppose that 



176 



the puncture of an intestine whose walls are inflamed 
and softened can be devoid of harm? If the needle 
penetrates the caecum or distended appendix, may it 
not produce a perforation which does not yet exist 
and which perhaps would not occur at all? On the 
other hand, suppose the needle, after having traversed 
the inflammatory focus, be thrust still more deeply, 
either into the walls of the iliac blood-vessels, or 
even simply into the sub-peritoneal cellular tissue. 
May it not inoculate these parts with the germs with 
which it becomes infected in traversing the morbid 
focus, and can one foresee all the possible conse- 
quences of such an inoculation? 

If, at least, the exploratory puncture furnished cer- 
tain and indisputable data, there would be more 
warrant for it, but a negative puncture does not 
prove the absence of pus. It is very evident that, if 
this means be employed, it is because the case is 
doubtful, the abscess therefore very limited or deeply 
located. In spite of three, four or more explorations, 
the needle may not happen to reach the pus cavity. 
This is not a gratuitous hypothesis. I can cite 
an observation of Bull, an advocate of the explora- 
tory puncture, a surgeon very skillful and familiar 
with these periappendicular lesions, where several 
punctures gave no result, and yet a free incision 
made immediately afterwards evacuated four ounces 
of pus. 

On the other hand, in numerous cases cited in its 



— Ill — 

support, the puncture was at least useless, for the in- 
cision made immediately after the needle had demon- 
strated the presence of pus, gave vent to so great a 
quantity of purulent liquid that one may confidently 
affirm that an attentive examination of the patient 
would have sufficed to reveal the suppuration, with- 
out the exploratory puncture with the trocar. 

We can, therefore, only endorse the judgment of 
Roux, of Lausanne : " Exploratory puncture is some- 
times dangerous, very often without result, and 
always useless." 

This surgeon indicates another means of diagnosis, 
which, he says, never has failed him: " If the caecum 
is shown to be empty of faecal matters, either by the 
existence of spontaneous stools, or in consequence of 
purgatives or lavements, and one observes over this 
part of the large intestine a sensation of softish 
resistance, comparable to that which a cylinder of 
pasteboard gives when very soft and wet in warm 
water, one may be sure that pus exists. This special 
resistance, sometimes accompanied by a slight degree 
of dullness, is connected with the inflammatory infil- 
tration of the caecal walls, an infiltration which ren- 
ders them somewhat rigid and in every case percep- 
tible to palpation." x 

I cannot discuss the diagnostic value of this 
sign; it seems to me, however, that a simple, plastic, 



Roux. Rev. Med. de la Suisse Romande, April, 
12 



178 



non-suppurative inflammation, might perhaps deter- 
mine the same infiltration and, consequently, on palpa- 
tion give a similar sensation. 

In fact in the acute forms with frank evolution, it 
is the attentive study of the course of the disease 
itself which gives the surest information. The ex- 
treme intensity of the symptoms of local peritonitis 
may in certain cases cause the medical attendant to 
suspect suppuration after the first four or five days, 
but even then it would be rash to affirm that the 
inflammation will not terminate by resolution. 

In general, it is impossible to pronounce with cer- 
tainty till after the seventh or eighth day. At this 
moment there takes place a lull in the general and 
febrile phenomena. This lull is complete and defini- 
tive, at least for some time, when the inflammation 
is simply fibrinous; the fever falls, the general state 
goes on improving each day. If, on the contrary, 
the peritonitis is suppurative, the lull is incomplete; 
the fever persists, no longer elevated and continuous 
but irregular, normal in the morning, mounting to 
38.6° and 39° in the evening, accompanied by a gen- 
eral malaise, by a restlessness which may be sub- 
dued in the morning, but comes on again in the even- 
ing or in the night time. Hence it is desirable to 
watch the patients closely, to examine them several 
times in the day, not only to note these variations of 
the febrile state, but to appreciate the modifications 
presented by the local phenomena, the augmentation 



— 179 — 

of the tumor, the possible tendency to extension of 
the peritonitis. 

After the eighth day one necessarily refers these 
symptoms of aggravation to the presence of a puru- 
lent effusion, and in the frankly acute forms, the 
temperature rises again towards the 10th and 12th 
day, which confirms the diagnosis of suppuration. 

But it will not do to forget that there may be pus 
without any great febrile movement and even with- 
out any fever at all, that the signs of peritonitis may 
be scarcely marked, that there exist, in a word, cases 
with abnormal evolution, corresponding to the forms 
which we have classed under the name of sub-acute 
appendicitis. It is very rare here that the diagnosis 
can be made early; no rule can be laid down; and in 
order to arrive at the conclusion that there is a col- 
lection of pus, the medical attendant will rely on the 
detection of a deep swelling more or less well defined, 
and on the bad general state of the subject, his 
cachectic aspect, and the tendency to intermittent or 
remittent febrile accessions, etc. 



VI. 

THE TREATMENT. 

As long as appendicitis was called typhlitis, and it 
was believed that the lesions were seated in the 
caecum, the treatment remained almost exclusively 
medical. Indeed, it could not be otherwise, for no 
one would have thought of incising the large intestine. 
The surgeon was not called till the pus, after doing 
more or less mischief internally, came to point under 
the skin in some part of the abdominal wall, and then 
it was generally too late to save the patient. 

We must, however, remember that 35 years ago 
Dr. Lewis, of New York, recommended an early 
incision. He had collected 47 cases of suppurative 
perityphlitis treated by the ordinary methods, with 
only one cure. He logically concluded that these 
methods were insufficient; that it was not necessary 
to wait till the pus collected and pointed in plain 
sight before operating, and that a free opening should 
be made as soon as the presence of pus in the iliac 
fossa was suspected. 

Twenty years later, in 1875, another New York 
surgeon, Dr. Gouley, insisted on the necessity of 
early opening of the abscess to prevent its rupture 
into the peritoneal cavity or elsewhere. The incision 
should, he said, be made as soon as the symptoms 
become threatening and even before fluctuation is 



— 181 — 

manifest (as early even as the seventh or eighth day). 
He gave statistics of 25 cases of typhlitis occurring in 
England and America, which were treated by an 
early incision; of these there were 17 recoveries and 
eight deaths. 

A more precise knowledge of the causes and seat 
of the suppuration, and the discovery that appendi- 
citis is so often perforative, naturally gave impetus 
to the surgical treatment of the disease. 

We have seen that as early as 1827, in his remark- 
able memoir on the diseases of the appendix, Melier 
had foreseen the part that surgical intervention was 
to play in the treatment of inflammations of the ap- 
pendix. " If," said he, " it were possible to make 
a certain diagnosis of these affections, we should be 
able to save all our patients by means of an opera- 
tion. Possibly the day will come when we shall be 
able to do this." 

The prevision of Melier is to-day realized — we 
may even say exceeded, for surgeons have now at- 
tained such a degree of confidence that many (and I 
allude in particular to certain American surgeons) 
no longer wait for the indications formulated by the 
more conservative authorities, but propose an im- 
mediate laparotomy for every case that presents itself. 

Naturally there has been a reaction against this 
zeal for the use of the knife. To the triumphant 
statistics of the surgeons, the physicians have replied 
by statistics no less decisive; for instance, those of 



— 182 — 



Guttmann, where out of one hundred cases re- 
corded as typhlitis and perityphlitis the medical 
treatment gave ninety-six (96) recoveries and four 
(4) deaths. 

We do not believe that this question can be de- 
cided by an appeal to statistics, for we never know 
how many mistakes statistics may cover. But in 
the presence of such figures as the above, even if 
we should have to admit a large portion of mistakes 
of diagnosis and incomplete recoveries, we should 
still be warranted in concluding that medical means, 
and even expectancy, are not absolutely valueless, 
that the bistoury is not always the ultima ratio, and 
that henceforth we may at least try provisionally, in 
many cases, a less heroic mode of treatment. 

This leads us back to the position before mentioned 
— that there exist divers forms of appendicitis, and 
that the first duty of the physician is to make a precise 
differential diagnosis. Yet if we are to judge from the 
numerous discussions which have taken place in var- 
ious medical societies at home and abroad, the sur- 
geons, taking account only of cases where their in- 
tervention has been required, do not seem willing to 
admit the existence of more than one kind, namely, 
perforative appendicitis with peritonitis or suppura- 
tion. . 

Their reason seems to me to be as just as if, from 
the good results obtained by pleurotomy in purulent 
pleurisy, one were to conclude that every case of 



— 183 — 

pleurisy is necessarily suppurative, and that the only 
treatment to be thought of in pleural inflammation is 
the free incision of the thoracic parietes. 

27. Medical Treatment. 

We have said that appendicitis may be divided 
into medical and surgical. The appendicites prop- 
erly medical comprehend those forms in which the 
inflammation is limited to the walls of the appendix, 
or gains by propagation the peritoneal membrane to 
a certain extent; i. e., appendicular colic, simple 
parietal appendicitis, and appendicitis with partial 
fibrinous peritonitis. 

The treatment of these kinds is indisputably 
medical — calmatives, evacuants, local antiphlogistics; 
we may add intestinal antiseptics. 

The indication in appendicular colic is the same as 
in hepatic or nephritic colic, i. e., to assuage the 
pain, which is due to the same cause as in renal or 
biliary lithiasis — the painful contraction of a 
musculo-membranous tub# due to the presence of a 
foreign body. The subcutaneous injection of -J- to i 
grain of morphia meets this indication. In allaying 
the pain, it suppresses or diminishes the muscular 
spasm and the consequences of the reflex irritation 
starting in the appendix; and, in suppressing the 
spasm, it may facilitate the expulsion or return of 
the stercoral calculus into the caecum. 

The medical attendant will apply at the same 



184 



time, over the abdomen of the patient, hot poultices 
sprinkled with laudanum. If nausea and vomiting 
exist, effervescent drinks, menthol, little bits of ice, 
etc., may be prescribed. 

The physician is rarely called to witness an acute 
attack of appendicular colic. When he reaches the 
patient, either the severity of the attack is over, or 
there remain only vague abdominal pains with a 
sensitive point douloureux in the right iliac fossa. 
Here the attention should be concentrated. If the 
fixed pain is but little marked, if the abdominal 
walls are relatively supple, the physician will con- 
tinue the poultices, perhaps order a full bath, and 
administer an emollient or oleaginous enema. It 
would be useless to administer at this time a purga- 
tive, which might provoke new and unseasonable 
contractions and give rise to a second acute crisis by 
forcing back into the appendix the scybalous concre- 
tion now perhaps partly or completely disengaged. 

If, on the contrary, there exist local signs of a se- 
vere appendicular irritation, if the iliac region is very 
painful and tender, if the muscular tension over this 
region is very marked, the application loco dolenti of a 
dozen leeches should be prescribed. It is certain that 
this local blood-letting always brings great relief; it 
is probable that it causes a decongestion or depletion 
of the walls of the appendix, at this moment turges- 
cent and rigid, as if in erection, as the very early in- 
cisions of the American surgeons have often shown. 



— 185 — 

Profiting by this lull in the pain, the physician may 
administer a purgative dose of calomel or an ounce 
of castor oil. 

On this question of the employment of purgatives 
in appendicitis, physicians are divided into two par- 
ties; the one favors their systematic administration, 
the other discards them from fear of favoring perfora- 
tion. These are extreme positions; there is a proper 
mean between them. 

At the onset it is well to refrain from purgatives, 
because at this moment the intestine, which is vio- 
lently excited and under powerful contractions, might 
force still farther into the appendix the coprolith and 
effect its permanent lodgment there. At this period 
the fear of favoring perforation is legitimate, as the 
intensity of the appendicular inflammation is in the 
ratio of the degree of constriction exercised by the 
foreign body on the walls of the diverticulum. 

But after the depletion produced by the application 
of the leeches, the danger is much less, and a purga- 
tive may even be given with benefit. Not only does it 
empty the large intestine, which is always a relief to 
the patient, but it arouses the normal peristalsis of 
the muscular coats, which, in being propagated to the 
walls of the appendix (now become less engorged and 
less tense), may provoke the expulsion of the copro- 
lith from the canal of the appendix. 

We would recommend neither drastics which cause 
too violent contractions, nor salines which cause a 



186 — 



serous secretion which is abundant and does no good. 
Castor oil and calomel, producing milder effects, are 
more suitable. I prefer castor oil, as it more readily 
carries along the mass of hardened faecal matters 
which have accumulated in the colon by the reflex 
paresis of the muscular coat. My method is to give 
it in doses of a teaspoonful every half-hour or hour 
till a full stool is obtained. 

The days following, freedom of the bowels is kept 
up by laxative and antiseptic lavements, i. e., lave- 
ments to which boric acid or naphthalin is added. To 
prevent intestinal fermentation and the formation of 
gases, it is also well to administer by mouth divers 
substances which favor intestinal antisepsis, such as 
salol, naphthol, betol, and benzo-naphthol. 

These means ordinarily suffice to stay the progress 
of a case of parietal appendicitis. 

If a new inflammatory invasion takes place, and 
especially if this be complicated with the signs of a 
partial fibrinous peritonitis, it will be necessary to re- 
new the application of the leeches and have recourse 
to frictions with mercurial and belladonna ointment. 
Opium may be given at the same time in doses of -J- to $ 
grain, repeated two. three, and four times a day, to 
immobilize the intestine and prevent the extension of 
the serous inflammation. The application of an 
ice-bag to the abdomen also gives good results. 

It is understood that from the very onset of the 
affection the patient must be kept rigorously in bed 



— 187 — 

(dorsal decubitus), on a diet of milk or broths, or 
light gruel, etc. 

The sojourn in bed should be continued some time 
after the cessation of all local pain. As long as you 
perceive in the right iliac fossa the little elongated 
tumor formed by the thickened and dilated appendix, 
the greatest prudence is indispensable, for it is not 
rare to see a recrudescence of the disease produced 
on the occasion of a strain, a violent movement of 
the patient, or too great haste in quitting the bed 
(the latter especially). 

Ought the medical treatment to be employed in, 
the surgical forms of appendicitis? I would reply 
emphatically: No! on condition that we are certain 
that it is really a case of perforative appendicitis 
with periappendicular suppuration. No one would 
think of favoring the resolution of an abscess of the 
subcutaneous cellular tissue by leeches, poultices, and 
mercurial inunctions. It would be foolish to attempt 
it under a pretext that the abscess is intraperitoneal. 

But we have seen that it is often very difficult, 
not to say impossible, during the first few days to 
decide whether the appendicitis is perforative, and 
whether suppuration exists. During this first per- 
iod, as long as perforation is not demonstrated, 
the physician not only can, but ought to, put in prac- 
tice the means indicated above. If perforation has 
not yet taken place, there is nothing to prove that 
this treatment, suitably applied and in time, may not 



188 — 



bring about the decongestion of the appendicular 
walls, and in consequence prevent the ulcerative pro- 
cess which ends in rupture into the peritoneum. On 
the other hand, supposing that perforation has taken 
place, it is quite possible that this same treatment — 
leeches, inunctions, opium, and ice — may be capable, 
not of preventing suppuration, but of limiting the ex- 
tension of the serous inflammation, and of restricting 
it to the immediate vicinity of the appendix. 

All depends, then, on the moment when the phy- 
sician is called to see the patient. If at the onset, 
.and at a moment when it is impossible to pronounce 
with certainty as to perforation, he ought to act as 
though he thought it a case of simple parietal appen- 
dicitis. His conduct will be the same as if the signs 
of a partial peritonitis manifest themselves, nothing 
yet warranting the belief that it is a case of perfora- 
tive appendicitis; experience having shown that this 
peritonitis may be due to a simple propagation of the 
parietal inflammation, and it may be purely fibrino- 
serous, consequently susceptible of resolution and 
resorption. 

Having passed the seventh or eighth day, the mind 
of the physician should be made up. He should not 
allow himself to be deceived by the temporary lull 
that takes place at this moment, so as to believe in 
the definitive arrest of an attack of simple fibrinous 
peritonitis when it is only a case of the limitation of 
a suppurative peritonitis which tends to circumscribe 



— 189 — 

itself. The medical treatment then becomes useless, 
save the administration of opium. It is necessary, at 
all events, to abstain from prescribing any new purga- 
tives, which can but provoke a new extension of the 
peritoneal inflammation. The time has come to call 
in the help of the surgeon. 

It is understood that these indications have but a 
relative value. It is as difficult to lay down absolute 
rules for the treatment as for the diagnosis of appen- 
dicitis. The aspect and inspection of the patient often 
teach more than the most minute descriptions. It is 
certain that there are cases where, as early as the 
second or third day, one may resolutely affirm per- 
foration; there are others — more rare, it is true — 
where even at the end of twelve to fifteen days one 
would scarcely suspect the true nature of the acci- 
dents. 

The only absolute rule that can be given is the fol- 
lowing: The moment the diagnosis of acute perfora- 
tive appendicitis with generalized peritonitis is made, 
or of appendicitis with periappendicular suppuration, 
that moment it is time to abandon all medical treat- 
ment and summon the surgeon, and let the responsi- 
bility of a laparotomy rest with him. 

The Surgical Treatment. 

Here the question presents itself which is always 
the most debated and which is likely to be debated 
for many years to come : At what moment should 
recourse be had to the bistoury. 



— 190 — 



We may range in three categories the views taken 
on this point. 

1. The old view, that of the temporizers who take 
the extreme position that no operation should be at- 
tempted until the abscess is ready to burst before 
your eyes. It has in its support the cases where 
recovery has taken place after a spontaneous opening 
and the evacuation of pus, whether outside the abdo- 
men or into the intestine or vagina. But it leaves the 
patient exposed to all the risks of deep abscesses, to 
purulent or putrid infection, to general peritonitis by 
rupture of the abscess into the peritoneal cavity, to 
purulent infiltration of the subperitoneal tissue and 
of the muscles, to the propagation of the inflammation 
to the diaphragm and pleura, to thrombosis of the 
iliac veins or of branches of the vena portse, with 
pulmonary or hepatic embolisms, etc. 

2. The extreme view of certain surgeons, who 
advocate precocious and instant laparotomy as soon 
as the diagnosis of appendicitis is made. These men 
support their position by the following arguments: 
"We never know that an appendicitis will not be per- 
forative; it is better, then, to remove the appendix 
before perforation has taken place than to run the 
risks of general or partial peritonitis. Numerous 
cases have a fatal termination in the first 24 to 48 
hours. Observations are not lacking where an opera- 
tion too tardily performed has failed to prevent a 
fatal issue which might have been avoided by an 



— 191 — 

earlier operation. Lastly, an operation, however 
early performed, is without gravity, and the utility 
of such operations is being every day proved." 

Do these arguments justify systematic surgical 
interference in the first 24 to 48 hours? The 
first argument need not long detain us. We can 
never, it is true, know that an appendicitis will not 
be perforative, but we are equally in the dark as 
to whether it loill be. And, moreover, if we take all 
the forms of appendicitis as they come, without 
making any distinction, we know with certainty that 
in 90 per cent, the disease gets well without the aid 
of the surgeon, which shows that, as far as the life 
of the patient is concerned, the immediate prognosis 
is not so very grave, and that one may safely wait. 

Certainly, if one could affirm, from the symptoms 
presented by the patient, that a case of appendicitis 
would be perforating in from 24 to 48 hours, there 
would be no warrant for hesitation, and it would be 
the physician's duty to advise laparotomy immedi- 
ately, before any sign of peritonitis had manifested 
itself. But, as before said, a positive diagnosis of 
this kind is seldom or never possible. 

Here is an instance of early operation — the earliest 
that I have any knowledge of, for it was performed j ust 
24 hours after the first symptoms appeared. The 
case is published by Dr. Dalton, of St. Louis. The 
patient, a vigorous man, aged 33 years, in the hospi- 
tal on account of sore eyes, was taken suddenly sick, 



— 192 — 



Dec. 25th, with a violent pain in the abdomen, refer- 
red to the umbilicus. Dr. Dalton saw him three 
hours afterwards, and diagnosticated appendicitis. 
The next day, just 24 hours after the onset of the 
attack, he operated. The temperature was then 
38.8° C, the pulse 116, respiration 32, the pain 
intense and almost continuous. A semilunar incision 
three inches long was made over the region of the 
appendix. The appendix was found running parallel 
to the caecum, and adherent to it by a very short 
mesentery. It was of a dark blue color, almost 
black, and largely distended — of the size of the little 
finger. There was not the slightest trace of inflam- 
mation between the appendix and the neighboring 
parts. The appendix was ligated and cut off close to 
its caecal origin. On examination it was found not 
to be perforated at any point; its canal was blocked 
by a very hard faecal concretion floating in a purulent 
liquid. Recovery was rapid. 

Would perforation have taken place here if lapar- 
otomy had not been performed ? From the appear- 
ance of the appendix this would seem probable, but 
only probable; for we do not know that in the simple 
forms which get well by medical treatment the con- 
gestion of the walls of the appendix is not just as 
intense. But at all events, if we compare the symp- 
toms complained of by the patient with those of 
simple parietal appendicitis, we find no peculiarity to 
warrant the belief that perforation was more to be 



-- 193 — 

feared than in simple appendicitis. Certainly a fever 
heat of 38.8° C, a pulse of 120, and an intense and 
continuous pain in the iliac fossa, are observed at the 
onset in the most benign forms of appendicitis. 

We have, then, we repeat, no means of foreseeing 
the perforation of the appendix — a prevision which 
alone would justify an operation in the first twenty- 
four to forty-eight hours. The position of the parti- 
sans of this extreme view would, then, necessitate 
the opening of the abdomen for every attack of in- 
testinal colic attended with intense pain localized 
in the right iliac fossa — a rule sufficiently absurd in 
itself, and which medical men will be very slow to 
adopt in their practice. 

The second argument is that a certain number of 
subjects succumb as early as the second day of the 
disease. This number is not as large as one might 
suppose, for out of 176 fatal cases Fitz could find 
but eight in which death took place during the first 
forty-eight hours. It would seem, moreover, very 
probable that these cases belonged to the acute form 
with general peritonitis — a form which is almost cer- 
tainly fatal and where surgical intervention from the 
very first would not save the patient. These rapidly 
progressive cases, being exceptional, ought not to be 
the basis of a general rule of treatment; in an im- 
mense majority of cases the progress of appendicitis 
is much slower. 

As for the third argument, that an operation per- 

13 



— 194 



formed too late is a calamity to the patient and an 
opprobrium to the surgeon: that is very true, but it 
does not justify too early an operation. All we can 
say is, better that it should be early than late. 

There remain to be considered, the little gravity of 
the operation, and the good results obtained from 
early laparotomy. Out of 24 cases thus treated by 
McBurney — six on the second day, fourteen the third 
day, two the fourth day, two at the end of a week — 
there were 23 recoveries and but one death. I would 
not think of contesting either the progress of aseptic 
surgery or the facility and safety with which to-day 
surgeons open the abdomen. But the fact that an 
operation is not necessarily serious, does not justify 
it if it is not necessary; and we should like well to 
know in how many of McBurney's 24 cases the opera- 
tion was indispensable to save the life of the patient, 

3. We have now to consider an intermediate posi- 
tion, that of those who believe in an early operation 
but only when the urgency and gravity of the symp- 
toms furnish indications which the reason and judg- 
ment of the physician cannot well misinterpret. No 
precise time can be fixed for such "early" operation; 
the limits vary from the third to the fifteenth day. 
To discuss whether, as a general rule, it is better to 
operate before the fifth day, which certain American 
surgeons insist upon, or after the fifth day, as Treves 
urges, seems to us unprofitable. We say once more, 
everything depends on the case and on the form of 



— 195 — 

appendicitis. The truth is that the distinction which 
we have established between the highly acute forms 
with general peritonitis, and the acute forms with 
circumscribed peritonitis, should be kept in mind as 
a guide in deciding whether and when it is best to 
operate. 

In the hyper- acute forms there is no middle course; 
either you must operate immediately or leave your 
patient to die. A diffuse peritonitis caused by intes- 
tinal perforation never gets well; to wait is to let 
your patient become exhausted by the violence of 
the inflammatory shock, or infected by the putrid 
products formed in the peritoneum. Besides, it is 
this hyper-acute form which kills rapidly — the sec- 
ond, third or fourth day. It is necessary, then, to 
make haste, if you wish the operation (which is 
the patient's only chance of life) to succeed. The 
chances for life offered by laparotomy are not very 
great; it is probable that they are nil after the 
fifth day. Yet there is certainly some chance if the 
operation is done in time, if the collapse is not too 
great nor septicaemia too far advanced. The prema- 
ture interference of American surgeons has at least 
established this fact. You cannot, then, operate too 
soon when the symptoms leave no doubt as to the 
existence of a peritonitis general from the start. 

In the frankly acute forms with partial peritonitis, 
with or without tendency to progressive extension, 
the urgency is not so great. In fact, in the great 



196 



majority of cases which have been published, the 
operation was not performed till in the course of the 
second week. Hence, the rule given by American 
surgeons, that one ought to operate as early as the 
third day, if at this moment the patient does not ex- 
perience a marked amelioration under the influence 
of abstinence, rest, opium, purgatives, and topical 
applications, seems to us inadmissible in such cases. 
We prefer for the acute circumscribed forms Treves' 
rule : JVot to operate before the fifth day. But with 
this reservation understood, it remains to determine 
what is the most opportune moment to operate. 

Now, in our judgment, it is extremely difficult to 
decide on the fifth day whether Or not the partial 
peritonitis is suppurative, or whether it is due to a 
perforation of the appendix or to a propagation of a 
parietal inflammation. To lay down a rule that the 
operation should be performed on the fifth or even 
the sixth day, is in reality to act as the American 
surgeons advise and to perform the operation in all 
cases that present violent or serious symptoms. It 
is, in fact, risking a laparotomy for a simple partial 
peritonitis, which might have got well without an 
abdominal incision. 

One might, without doubt, run this risk of an 
operation in itself needless (though in reality of 
little gravity) if in cases where the peritonitis is sup- 
purative a delay of several days exposed the patient 
to mortal dangers. But do these dangers exist on the 



eighth or ninth days more than on the fifth or sixth? 
We do not hesitate to reply in the negative, the 
moment that the peritonitis tends to become circum- 
scribed. 

We may even add that in such cases it is even an 
advantage not to act too precipitately. Beside the 
fact that this relative temporizing enables us to 
determine with more certainty the diagnosis of sup- 
puration, it favors the limitation of the focus of 
suppuration, its more complete separation from the 
peritoneal cavity, and the formation of firmer 
adhesions to the abdominal wall. Now, the pub- 
lished observations show that the longer the opera- 
tion is put off the more easily it is performed; in 
fact, the surgeon has simply a deep abscess to open. 
You have only to run over the series of facts 
reported by Roux, of Lausanne, to see that out of 23 
cases operated on from the seventh to the fifteenth 
day there were only two deaths — one by embolism, 
the other by diffuse peritonitis; while out of twelve 
cases in which the operation was performed from 
the second to the sixth day, there were three deaths. 
In two of these twelve cases (which recovered) the 
signs of general peritonitis manifested themselves 
early and made the necessity of an immediate opera- 
tion sufficiently apparent. 

We are, then, inclined to believe that in the acute 
frank forms with partial peritonitis the most oppor- 
tune moment for the operation, unless special and 



— 198 — 



urgent indications should present themselves, is after 
the first week — from the eighth to the twelfth day, 
during that period of temporary lull, scarcely marked 
by any fever heat, which follows the first febrile 
phase of the malady, and which precedes the fever 
of purulent resorption. To operate earlier is to run 
the risk of performing a needless operation, as the 
peritonitis may be simply fibrinous; or even to run 
the risk of infecting and inflaming the totality of the 
peritoneum, the protective limiting adhesions not 
being sufficiently formed or sufficiently resisting. To 
wait till a later period is (without possible benefit) 
to leave the patient to become exhausted and to be 
exposed to the chances of one of those unforeseen 
complications which supervene abruptly to aggravate 
an affection hitherto benign, or indefinitely to pro- 
long its duration. 

While this is the general rule as to surgical inter- 
vention, it may well be that the progress of the sup- 
purative peritonitis is so rapid that on the fourth or 
fifth day there is no longer any doubt as to the pres- 
ence of a purulent collection well limited; in this 
event one cannot do better than to operate at once 
and no later than the fifth day, as Treves advises. 
For a greater reason, if the general symptoms are very 
threatening, indicating an extreme depression or a 
well marked septicaemia, if the peritoneal inflamma- 
tion gains rapidly instead of tending to become cir- 
cumscribed, the operation should not be delayed 



— 199 — 

another day; it is, of course, needless to say that 
with such symptoms the best surgical skill cannot 
offer much hope. 

In the case of children, according to Morton, we 
should operate earlier than in adult patients, because 
the progress of the appendicitis in infantile life is 
more rapid, the tendency to invasion of the periton- 
eum greater, and the termination more frequently 
fatal. This is true in the sense that in the infant, as 
we have said, it is the perforating hyper-acute form, 
with general peritonitis at the onset, which is most 
often observed. But it must not be forgotten that 
we also see in the infant very acute forms which 
limit themselves to an attack of simple partial peri- 
tonitis, and which get well rapidly by purely medi- 
cal treatment. If, then, the diagnosis of general 
peritonitis by perforation is not doubtful, resort 
should be instantly had to laparotomy; but if it is a 
case of partial peritonitis, the management of the 
case will be precisely as though the patient were an 
adult, and the physician will not operate unless he is 
convinced of the presence of pus. 

In the hyper-acute forms, the physician should 
regulate his line of conduct according to the old 
axiom: "Ubi pus, ibi evacua^ One hardly ever 
runs the risk of operating too early, as the diagnosis 
is always tardy. And it is important here to operate 
the more promptly from the fact that pus tends 
silently to infiltrate distant parts and to produce in 



— 200 — 

the muscles and neighboring tissues disorders often 
irreparable. 

To sum up: Theoretically r , surgical interference is 
indicated as soon as the diagnosis of perforative 
appendicitis is made. Practically, this interference 
should be immediate in the forms attended with 
peritonitis which becomes general from the onset; it 
is the only chance which remains for the patient's 
life. It ought, in our judgment, to be put off till the 
eighth or twelfth day in the forms with partial per- 
itonitis, as the diagnosis of suppuration cannot be 
made certain during the first week, and the chances 
of recovery seem to us the greater the more thor- 
oughly the purulent collection is encysted. 

In the other forms of appendicitis, parietal or com- 
plicated with peritonitis by propagation, medical 
treatment ought alone to be employed — an operation 
made under pretext of preventing perforation being 
unjustifiable, considering the enormous proportion of 
cases which get well without the help of the bis- 
toury. 

29. The Operation. 



The best method of laparotomy, as all authorities 
admit, is by the lateral incision in the iliac fossa. 
Some make it along the right semi-lunar line; others 
obliquely, parallel with Poupart's ligament. 

According to Treves, the semi-lunar incision is 
bad, because it does not permit direct evacuation of 



— 201 — 

the pus. It is better to make an oblique incision, 
directed from above downward and inward, external 
to the deep epigastric artery, terminating a little 
above and outside of the middle of Poupart's liga- 
ment, following the general direction of the incision 
made for the ligature of the iliac vessels. 

The oblique incision is also the one adopted by 
Roux of Lausanne. He makes it parallel to Pou- 
part's ligament, one-half inside and the other half 
outside the antero-superior spine of the ilium, from 
which it is separated by l£ to 2 centimeters. It is 
necessary to avoid as much as possible the epigastric 
artery, which should be left at the internal part of 
the lower extremity of the incision. Grave secondary 
hoemorrhages have been seen in consequence of 
wounds of this artery (Morton). 

This oblique incision allows the surgeon to reach 
the purulent collection by pressing inward the 
intestinal coils agglutinated in the iliac fossa. In 
order to operate with certainty, the incision should 
be sufficiently long — 3 to 4 inches, say the American 
surgeons; 15 to 18 centimeters, says Roux of 
Lausanne. It is better not to have the incision too 
long, for that would favor ventral hernia later on. 

The surgeon incises layer after layer down to the 
transver salts fascia. Having reached this point, he 
incises the peritoneum only in the upper and outer 
portion of the wound, where he is certain of finding 
the caecum. " We then," says Roux, " engage the 



— 202 



index finger between the intestine, which we press 
inwardly, and the external abdominal wall; then we 
continue the exploration and the separation to the 
back part of the abdomen, when the pus does not 
well out at the first touch of the knife and there are 
indications that the seat of the abscess is in the retro- 
cecal space. If we find nothing, we complete little 
by little the section of the peritoneum, and continue 
to explore the iliac fossa, being careful how we 
separate the adhesions, and searching for the point 
of insertion of the appendix, that our labor may not 
be in vain. If the appendix is difficult to find, it is 
because it is embedded in a mass of adhesions, 
whence pus is easily made to flow into the wound." 1 
These explorations must be made with the greatest 
care. One must not forget that the adhesions are 
recent and consequently very fragile; that in explor- 
ing with the finger at haphazard and without pre- 
caution one might easily break such as are important, 
and cause irruption of pus into the large peritoneal 
cavity. At the same time, an attentive examination 
of the walls of the abscess, and the tracing out and 
bringing into light of any and all diverticula and 
prolongations which the pus sac may present, are 
indispensable. The pus cavity is often multilocular, 
with well formed dissepiments, and there is danger, 
of overlooking one or more of these pockets and 



Roux, Revue Med. de la Suisse Romande, April and May, 1890. 



— 203 — 

leaving them intact after evacuation of the prin- 
cipal "foyer;" and this would render the operation 
of no effect. 

Besides, the surgeon will search for foreign bodies, 
scybala, etc., which may be found in the abscess 
cavity. And lastly, he will endeavor to form an 
estimate of the condition of the appendix. 

Here an important question comes up: Should the 
appendix be resected and removed? 

In certain cases the question is easily answered; 
the appendix is already gangrenous and detached 
from the caecum; it floats in the midst of purulent 
debris, and escapes with the first flow of pus, or may 
be easily removed with forceps. 

In other cases the appendix, though perforated and 
partly gangrenous, is still attached to the caecum, 
but is easily reached by the hand, and is found 
agglutinated to the walls of the abscess or to an 
intestinal coil. The thing to do then is to put a 
tight catgut ligature above the gangrenous parts, at 
a point where the tissues seem sound, then to cut 
and remove all the diseased portion. According to 
Treves, if the gangrene is total, or if the perforation 
is seated in the vicinity of the point of caecal attach- 
ment, it is better not to attempt to apply a ligature 
or remove the appendix — the elimination will take 
place of itself and without danger. 

But there are cases where the appendix, deviated 
or fixed in an abnormal position, or lost in the midst 



204 — 



of plastic peritoneal exudates, cannot be found. 
Shall we persist in hunting for it, and in detaching 
it from the adhesions which bind it down ? Most 
authorities counsel letting it alone. " When the ap- 
pendix," says Treves, " is very adherent, it is better 
to make no attempt to remove it by dissection, or 
even to separate it from its adhesions." 

Weir thinks also that it is well to excise the 
appendix when it can be easily reached, but it is not 
best to lose time in searching for it. It does not 
seem to do any harm, he says, when it is left, and 
ordinarily it sloughs away in a few days. 

MacBurney is also of opinion that it is best not to 
waste time in the search for the appendix; but he 
adds that to leave the appendix behind is not with- 
out danger. 

Porter takes the same view, and reports a case in 
which, after an operation for suppurative perity- 
phlitis, the appendix was left behind and gave rise 
to a series of recurrences which finally necessitated 
its ablation at the end of a year. 1 

Morton insists that the operation cannot be re- 
garded as complete unless the appendix is removed. 
Fear of opening the peritoneal cavity should never 
lead one to hesitate to dissect with the finger in 
order to expose the appendix, and then to resect it. 
•The only contrary indication is when the appendix is 



1 Boston Medical and Surgical Journal, Dec. 25, 1890. 



— 205 — 

lost in the midst of a thickened and resistant mass of 
plastic adhesions, which would render the isolation 
and ablation of the organ so difficult or so prolonged 
as to jeopardize the patient's chances. 

As will be seen, every case must be decided on its 
own merits and according to the degree of vital 
resistance of the patient and the time required for 
the operation. In fact, the fear of breaking up use- 
ful adhesions and causing perforation into a healthy- 
peritoneal cavity will always hold a prudent surgeon 
in check, and prevent too prolonged a search for the 
appendix and too prolonged a dissection. While, 
then, regretting that he is not able to finish the 
operation and relieve the patient of a useless and 
dangerous organ, the operator will do well to hold to 
the rule laid down by Treves and Weir. 

After having attentively explored the walls of the 
abscess and disposed of the appendix (whether re- 
sected or left), the abscess cavity is carefully and 
gently washed out by means of a gentle stream, from 
a fountain syringe, of a warm antiseptic solution. 
When it is necessary to wash out the peritoneal 
cavity, as in the case of general peritonitis, only 
boiled water should be used. 

The surgeon then introduces deep down into the 
wound, to the bottom of the pus cavity, a large 
drainage tube or a tent of iodoform gauze. Some 
surgeons, while leaving a drainage tube or wick of 
gauze, advise to sew up the greater part of the open- 



— 206 — 

ing in order to oppose the tendency to hernia. The 
surgeon will, moreover, always be ready to remove 
the sutures if he should observe the supervention of 
swelling or of infiltration of the walls, or if drainage 
does not seem to go on in a satisfactory manner. 

If the total gangrene of the appendix or rupture 
of the abscess into the intestine has produced an 
opening into the caecum, must the surgeon attempt, 
before completing the operation, to close up the 
opening by sutures ? No; sutures at this time would 
probably be useless and would not hold, although 
reunion has been once or twice attempted with suc- 
cess by means of Lembert's sutures. Moreover, the 
facts prove that caecal fistulas tend of themselves to 
cicatrization in a few weeks' time. If, however, the 
fistula does not close of itself, it may be necessary 
after a few months to make a new incision and 
freshen up the edges of the opening into the caecum, 
then to close the opening with Lembert's sutures. 



30. Treatment op Relapsing Appendicitis. 

The following course of conduct will probably 
meet with favor among surgeons: If, after a series 
of repeated attacks, which are near together, the 
diagnosis of relapsing appendicitis is regarded as 
beyond question, and there are, after careful explor- 
ation, good reasons to believe that the appendix is 
only thickened and dilated, one may, as Treves 
advises, properly await the interval between two 



— 207 — 

attacks to make the resection, which in such a case 
is ordinarily very easy. Secondly, if the relapses are 
due to the existence of a purulent collection in the 
neighborhood of the appendix, provoked probably by 
a foreign body, and especially if each return is 
accompanied by the formation of an external 
abscess, the surgeon will make a free incision during 
an attack and evacuate the pus and irritant body, 
and will excise the appendix if it can be easily found. 
Finally, if the relapses are very numerous and, 
according to the clinical characters which they 
present, seem to be due to repeated attacks of plastic 
peritonitis, and if in consequence there is reason to 
suspect old and thick adhesions, it might be well to 
follow the advice of Dennis and Morton and wait 
till another and severer attack shall overcome any 
hesitation on the part of the patient. The presence 
of numerous strong adhesions limits the area of in- 
flammation, and renders little probable any further 
extension to the peritoneum and the dangerous con- 
sequences which Treves thinks are likely to follow 
an operation made during the acute inflammatory 
stage. Doubtless the task of the operator will not 
be facilitated by virtue of such acute inflammatory 
attack. 

The following are the rules laid down by Treves 
for the operation when done in the interval of two 
relapses: Every symptom of inflammation having 
ceased^ and the position of the appendix being deter- 



208 — 



mined as nearly as possible, the incision will be made 
obliquely from above downward and inward, over 
the caecal region, its inferior extremity terminating 
just outside the epigastric artery. The incision 
should not be made directly over the appendix or 
over the dull region; for by making the incision 
there you would probably encounter adhesions, and 
it would be difficult to know, whether you were or 
were not inside the cavity of the peritoneum. The 
caecum or the appendix may be found adherent to 
the anterior wall. The peritoneal incision will then 
be made with the greatest care. It is better that the 
parietal section shall open the abdomen exactly 
opposite the diseased region, where there exist no 
adhesions. When the appendix and the caecum are 
uncovered, the field of operation will be separated 
by sponges from the great abdominal cavity; if this 
be well done, not a drop of blood will enter the peri- 
toneal cavity. All the adhesions will be divided on 
the bistoury; they must not be torn; by tearing 
them the surgeon would run the risk of lacerating 
the intestine or peritoneum. The appendix will be 
divided half an inch from the caecum; the surgeon 
will not be content with tying it with a simple liga- 
ture. The mucosa will be brought together by 
several fine sutures or by a continuous suture; then 
the external coats will be approximated by a new 
line of sutures. When the walls are very thick, it 
is impossible to suture the serous coats together. To 



— 209 — 

render certain the obliteration of the orifice, the sur- 
geon will fix the stump of the appendix to some 
neighboring portion of the peritoneum. The abdom- 
inal incision will then be closed; no drainage tube 
is to be inserted. During the operation every 
adhesion liable to become the cause of after-troubles 
should be destroyed; this applies more particularly 
to omental adhesions or to those which may exist 
between the intestinal coils. 

Such are the rules laid down by Treves and fol- 
lowed by most surgeons, English and American, in 
the treatment of relapsing appendicitis. 

I will in closing call attention to a last point, i. e., 
the possibility of a ventral hernia as a consequence 
of the operation. This kind of hernia does not seem 
to be rare in America; Bull says he has seen a dozen 
cases of it in the space of a few months in New 
York. Hence the American surgeons insist on the 
necessity of carefully making the suture of the walls 
layer by layer; it is the best means of insuring a 
solid union by first intention and avoiding this dis- 
astrous consequence. It is, moreover, a good plan 
to have the patient wear for some time a Glenard's 
abdominal belt, as Roux of Lausanne advises. 

In fine, whether the case is of acute or chronic 
form, the treatment of appendicitis cannot belong 
exclusively to either the physician or the surgeon. 
The first has too great a tendency to temporize, 
which is often fatal to the patient; the second is too 



— 210 — 

prone to have immediate recourse to the knife, which 
is often unnecessary. Only the harmonious coopera- 
tion of the two can bring about a wise and whole- 
some appreciation of the responsibilities and duties 
of the situation. 

"The first indication in appendicitis," says W. W. 
Keen, " is to call in the surgeon." This is true with 
some qualification. The physician should know just 
when to summon the surgeon, and the surgeon just 
when to operate and when not to operate. 



Convenient Preparations for Surgeons 



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Cascara Cordial and Glycerin Suppositories are eligible 
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Descriptive literature of our products sent to physicians 
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